Pet Drop Off Information Form

Pet Drop Off Information Form

Owners Name:___________________________

Pet’s Name______________________________

Date:____________________________

Circle the correct answers below:

My pet is indoors: All the time Most of the time Half the time A little Never

My pet’s water consumption is: Normal Increased Decreased

My pet’s appetite is: Normal Increased Decreased

Name of food my pet eats:______________________________

My pet is on medications: Yes No

If yes, name and dose of medications:_________________________________________

_______________________________________________________________________

Last dose given:________________________ A.M. P.M.

Concerns/Problems for the doctor to examine today:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

My pet has had this problem for: ____ Hours _____ Days ______Weeks _______Months ________Years

Has it been getting worse? Yes No

Has this problem been treated before? Yes No If yes, at what veterinary office so we may request previous records:_________________________________________

Has pet been vomiting: Yes No

If yes, how often? _________________ When was last episode?____________________

My pet has diarrhea: Yes No

If yes, how often?__________________ When was last episode?___________________

My pet has eaten today: Yes No If yes, what time?__________________________

Are there any other problems your pet has that we should know about? If yes, Describe:________________________________________________________________________________________________________________________________________________________________________________________________________________

To diagnose and treat many problems, blood tests, x-rays, or other tests may be needed. We will call you to discuss these procedures if they are needed or if we exceed the authorized amount below. In the even of a life threatening condition, we will make every attempt to stabilize your pet then notify you as soon as possible.

I authorize up to $_______________________ in diagnosis or treatment if needed.

Call me if additional procedures are needed: Yes No

Please make certain that we have a phone number where you can be reached at and when:

WORK #_________________________ Time available at this number______________

HOME #__________________________Time available at this number______________

CELL #___________________________Time available at this number______________

SIGNATURE:_____________________________ DATE:________________________