Drop Off Patient Consent

Examination Date:

First Name:

Last Name:

Email:

As the owner and guardian, I request and authorise a physical examination of the below pet;

Pet's Name:

Age:

Sex:

Male Female

Species:

Breed:

I understand that after examination the doctors will attempt to contact me to discuss recommendations for my pets care. The best number(s) to contact me today are as follows:

Phone:

From Time:

To Time:

If, despite our efforts, we are unable to reach you - please select one of the following:

Proceed with necessary diagnostics and treatment

Proceed with treatment but do not exceed requested value

Do not perform any additional treatment without speaking to a Doctor first

If proceeding with treatment, please advise maximum $ value:

Immediate costs will not exceed designated amount per owner

I understand that I assume financial responsibility for all services rendered, and that full payment is due upon discharge:

Yes, I understand.

I plan to pick up my pet at the following time today. I understand that an appointment has been scheduled for that time and the doctor/technician will go over instructions and results at that time. I understand that pending potential emergencies, there may be a wait at the time of pick up, but that every effort will be made to prevent that.

Pickup Time:

History Questionnaire

Is your Pet Spayed/Neutered?

Yes No

Preventative

Is your pet on monthly heartworm preventative?

Yes No

If so, what brand do you use?

Heartguard Interceptor

Do you use the preventative year round or seasonally?

Other?:

Is your pet on a monthly flea and tick preventative?

Yes No

If so, what brand do you use?

Advantage Advantix Frontline Vectra

Do you use the preventative year round or seasonally?

Other?:

Any additional flea/tick products you use on your pet?

Current Diet

Brand:

Meals Per Day:

1 2 3 4

Canned or Dry:

People Food:

Other History:

Current medications?

Current supplements:

History Questionnaire

Preventative

Current Diet

Medical Care