Drop Off Form

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Drop Off Form

This form is only for pet's that are being dropped off for an emergency exam, and an appointment must be scheduled with us before you fill out this form. This form does not secure an appointment, it just supplies us with the necessary information we need!

Please answer these questions in as much detail as possible for us to be able to thoroughly assist your pet.

Owner and Pet Information

Owner's first and last name *

Pet's name *

Phone number we can reach you at *

Second phone number

Information on Pet's Situation

Please fill out to the best of your ability

Injury? *

Yes

Other:

Injury: what type?

Injury: when did it occur?

Injury: where is it located?

Lameness? *

Yes

Other:

Lameness: type

when walking

when running

weight bearing

non-weight bearing

Other:

Lameness: which leg?

right front

left front

right rear

left rear

Other:

Clear selection

Vomiting? *

Yes

Other:

Vomiting: for how long?

If vomiting, is it...?

food

liquid

foreign material

Other:

Clear selection

Diarrhea? *

Yes

Other:

Diarrhea: how long?

Diarrhea: description

soft

watery

bloody

mucous

Appetite *

Normal

Increased

Decreased

Other:

Water intake *

Normal

Increased

Decreased

Other:

Describe your pet's current issue to the best of your ability: *

Is your pet's problem getting worse? *

Yes

Other:

Has this issue been treated before? *

Yes

Other:

If this issue has been treated before, please list your previous vet

May we request these records?

Yes

Other:

Clear selection

What medications have been given today?

Has your pet eaten today? *

Yes

Other:

Are there any other problems we should know about?

Authorization

To diagnose and treat many problems, blood tests, x-rays, and other tests may be needed. We will call to discuss these procedures as their need arises. We will also call if the amount exceeds the cost you give us below. In the event of a life threatening condition, we will make every attempt to stabilize your pet and then notify you as soon as possible. Please make certain that we have a phone number where you can be reached.

Best phone number to reach you at *

"I authorize up to $____ in the diagnosis or treatment if needed. Call if additional procedures are needed." (please enter a numerical value) *

Owner/Agent full legal name as a signature *

Date *

YYYY

Submit

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