Drop Off Intake Form
Pet with health needs
Sign in to Google to save your progress. Learn more
Date of Drop Off *
MM
/
DD
/
YYYY
Owner Name: *
Pet Name: *
What is a good phone number for urgent questions today? *
What brought you in today? Please briefly describe all symptoms related to illness.  Also, please include a timeline of when symptoms started/occurred. *
When was your pet last completely normal? *
MM
/
DD
/
YYYY
When did your pet last eat? *
MM
/
DD
/
YYYY
Eating with normal appetite? *
Is it possible that your pet got into any possible toxins or could have eaten any foreign material (toys, laundry), etc? (If yes, please list) *
Has your pet been to a boarding facility or dog park lately? *
If so, when was the most recent time?
MM
/
DD
/
YYYY
What medications, prescribed or over-the-counter, is your pet currently or has recently taken? *
What food does your pet currently eat? *
If your pet is due for vaccines and Dr. McKnight believes it is okay to be done, would you like your pet’s vaccines/routine wellness testing completed? *
Would you like any extra services, such as nail trim or anal gland expression, to be completed while your pet is here today? If yes, please list any requested services:
If recommended by Dr. McKnight,  Do you authorize: *
If total cost is to exceed $___________, please call for authorization prior to administering any diagnostic tests or treatment.
Do you plan on picking your pet up at a specific time (after 2:00pm)? If so, what time do you request your pet be ready (if possible)? ________________ Otherwise, we will call as soon as your pet is ready to be picked up. *
Time
:
I understand and acknowledge that payment is due in full for all services rendered at the time of pick-up *
Untitled Title
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms