Patient/Client Information

PET DROP-OFF FORM

Owner’s Name: _____________________________ Date: _______________________

Pet’s Name: ______________________________

Please leave a number where you can be reached at any time today should the doctor need to speak with you.

( )_______________________ or ( )________________________

Primary reason for visit: ______________________________________________________

Please list any additional services your pet needs today: ______________________________________________________________________

Has your pet had anything to eat today? Yes □ No □ If yes, what time? ____________

Regular food fed: ______________________________________

Please check all the symptoms that apply:

Vomiting	In Pain	Scratching
Diarrhea	Weight gain	Skin problems
Blood in Stool	Increased appetite	Increased water consumption
Lethargy	Decreased appetite	Coughing
Bad Breath	Tumor or mass	Sneezing

Please list all medication(s) your pet is currently taking and when the last dose was given:

Medication: ________________________________ Time given:____________________

If X-Rays are necessary for treating your pet today, do we have your permission? Yes □ No □

If blood work is necessary for treating your pet today, do we have your permission? Yes □ No □

If sedation is necessary for treating your pet today, do we have your permission? Yes □ No □

ANESTHESIA RELEASE :

I understand that the doctors and staff will use all reasonable precaution against injury, escape, or death of my pet. I understand that all anesthesia involves some minimal risk to my pet and will not hold the doctor and staff responsible under any circumstances. I understand that I assume all risks.

I give permission for my pet to be treated as described above and agree to be financially responsible.

_______________________________________

Signature of Owner or Guardian

PROCEDURE DROP-OFF FORM

Owner’s Name: _____________________________ Date: ________________________

Pet’s Name: ______________________________

Please leave a number where you can be reached at any time today should the doctor need to speak with you.

( )_______________________ or ( )________________________

Procedure being performed today: ______________________________________________

Any additional services: ______________________________________________________

Has your pet had anything to eat today? Yes □ No □ If yes, what time? ____________

Please list all medication(s) your pet is currently taking and when the last dose was given:

Medication: ________________________________ Time given:____________________

FOR DENTALS ONLY: Owner pre-approves any necessary extractions. Yes □ No □

FOR SPAY ONLY:

Please check any of the following that apply to your pet’s current condition or behavior.

□ Swollen Vulva

□ Bloody vaginal discharge

□ Restlessness, pacing, whining

□ Decreased appetite

□ Frequent urination

□ Receptive to males or attacking males