DROP OFF FORM Client Name: _________________ Patient # (Office use only) : _________ Pet Name: _________________ Today's Weight: _________ Number where you can be reached today: (____)________________________ Alternate Number: (____)________________________ Please check all symptoms that apply to your pet: Straining to urinate: _____ Panting: _____ Odor: _____ Frequent urination: _____ Vomiting: _____ Difficulty breathing: __ Constipation: _____ Coughing: _____ Hair loss: _____ Diarrhea: _____ Watery Eyes: ____ Restlessness: _____ Decrease in water intake: _____ Lethargic: _____ Scooting: _____ Increase in water intake: _____ Depressed: _____ Gagging: _____ Decrease in appetite: _____ Weakness: _____ Seizures: Increase in appetite: _____ Limping: _____ Shaking head: _____ Discharge: Where? _________ Color? ________ For how long? _________________ Pain: Where? __________________________ For how long? __________________ Growths: Where? ________________ When did you notice them? ______________ Behavioral Changes: Since when? _____________________________ What are they? _____________________________________________ If you have noticed diarrhea, how often are you noticing it? Since what date? Color and consistancy?____________________________________________________________ If you have noticed vomiting, how often are you noticing it? Since what date? Color and consistancy?  ___________________________________________________________ When did your pet last eat well? _________________________________ When did your pet last drink well? _______________________________ What does your pet's diet usually consist of? (Please be specific and include any treats, table scraps, ect.) _______________________________________________________ What brand of food are you feeding? ______________________________ Canned or dry? ________________________ How often are you feeding your pet? _________ What amount? _________ We have arranged for you to leave your pet here, to allow the Veterinarian to examine your pet as soon as possible. The Veterinarian will preform a thorough physical exam as soon as the schedule allows. For the benefit of your pet's health, it is important to start treatment as soon as possible. If reccomended, which procedures to you authorize? Diagnostics Treatments Bloodwork (Approx. $20-$85): _______ Fluid Therapy (Approx. $20): _______ Radiographs (Approx. $81): _______ Sedation (Approx. $45-$90): ______ Urinalysis (Approx. $25-$45): ______ Medication (Price varies): ______ Cytologic evaluation (lumps, bumps, ears) (Approx: $16-$85): _______ Other diagnostics and/or treatments: _______ Please inital here if you would like to be contacted prior to any treatments or diagnostics: _______ I am the owner/agent for this pet, and I authorize and request an exam for my pet. I understand that payment is due when my pet is discharged. I accept financial responsibility for charges incurred for this pet. I understand that I will be charged for flea medication if evidence of fleas is found on my pet. Signature: _________________________ Date: ______________
Please print out this form, fill in the information, and either bring it along with your pet, or FAX it to 866-866-7558