Animal Drop-Off Form "*" indicates required fields Step 1 of 4 25% The information requested will tell us the things you want us to do for your pet. It is the only way we can be certain that we understand what you want. Therefore, it is very important for you to be as specific as possible. If we need additional information, we can reach you at the number you give us today. Thank you!Owner’s Name* First Last Date* MM slash DD slash YYYY Any change in address or phone number?* Yes No Any Changes*Pet’s Name*Breed*Sex*Age*Species* Dog Cat Spayed/Neutered?* Yes No Phone number where you can be reached today* Is your pet sick?* Yes No Major Complaint?*How long & When did it begin?*Has the pet been treated for same condition recently?* Yes No How long?*Current diet?*How much food per day?*Does the pet eat human food?* Yes No Diet supplement given*Is the pet on Flea & Heartworm Prevention?* Yes No Dog Vaccines Required* DHLPP OR DHPP Bordetella Rabies Cat Vaccines Required* FVRCP Leukemia Currently Rabies VACCINATION DECLINE: “I understand that state law requires rabies vaccination for all pets. I also understand clinic policy requires Distemper / Parvo vaccination for dogs and / or Feline Distemper vaccine for cats to be current. I decline vaccination at this time because vaccinations have been given elsewhere and are current. If my pet bites another animal or person while at this veterinary clinic, I will provide written evidence of a current rabies vaccination within 24 hours of notification to do so.”Owner/Agent InitialTests & Services* Physical Exam Intestinal Parasite Exam Deworm, if needed Feline Leukemia Test Heartworm Test Bath Dentistry Surgery None of the above HistoryAny injuries or accidents in the past 30 days?* Yes No What?*Any surgeries in the past 30 days?* Yes No What?*Allergic to any medications?* Yes No What?*Currently on meds or given anything with in 24 hrs?* Yes No What?*Appetite normal or did the pet eat/drink this am/pm?* Yes No How Long?*Vomiting?* Yes No How Long?*Diarrhea?* Yes No How Long?*Listless?* Yes No How Long?*Drinking more or less water than usual?* Yes No How Long?*Weakness?* Yes No How Long?*Coughing?* Yes No How Long?*Sneezing?* Yes No How Long?*Gagging?* Yes No How Long?*Urinating more or less than usual?* Yes No How Long?*Scratching?* Yes No How Long?*Shaking head?* Yes No How Long?*Limping?* Yes No Which Leg?*How Long?*Scooting?* Yes No How Long?*History of seizures?* Yes No How Long?*Unusual lumps or bumps?* Yes No How Long?*Bad breath?* Yes No How Long?*Weight Loss or gain?* Yes No How Long?*Unusual discharge?* Yes No How Long?* Reason for visit?*Any comments*Some pets require sedation for adequate physical exam, treatment, surgery or dentistry. May we sedate your pet if necessary?* Yes No Call first After examination by the DR, may we proceed with tests like Bloodwork or X-Ray’s?* Yes No Call first OWNER RELEASEYou are to use all reasonable precaution against injury, escape, or death of my pet. The clinic and staff will NOT be held liable for any problems that develop provided reasonable care and precautions are followed. In understand that ANY problem that develops with my pet while I’m absent will be treated as deemed best by the staff veterinarians and I ASSUME FULL RESPONSIBILITY for the treatment expense involved.* I assume full responsibility Please note: All patients will receive a Capstar upon arrival if fleas are present.* I understand Signature*Date* MM slash DD slash YYYY CAPTCHA Δ
