Briarcliff Animal Clinic Too

Drop-Off Release

Please check any problems that you wish to be addressed today:

[ ] Vomiting[ ] Itching[ ] Ear Problem[ ] Difficulty Urinating

[ ] Diarrhea[ ] Rash[ ] Eye Problem[ ] Difficulty Defecating

[ ] Coughing[ ] Hair Loss[ ] Tooth/Mouth Problem[ ] Increased Appetite

[ ] Fleas [ ] Licking Feet [ ] Behavioral Problem[ ] Decreased Appetite

[ ] Cut/Abscess[ ] Sneezing[ ] Excessive Thirst [ ] Weight Loss

[ ] Painful Area(s) [ ] Limping/Lameness[ ] Excessive Urination[ ] Weight Gain

Please describe any of the above problems or additional problems: ______

Does your pet visit: [ ] Wooded Areas [ ] Dog Parks [ ] Farms [ ] LakeHouse

[ ] Mountain House [ ] Other (if relevant)______

Is your pet on any medications (including flea/tick/heartworm products)?[ ] Yes[ ] No

If yes, please list name of medication(s), frequency and dose:

______

______

______

What brand food do you feed your pet and consistency (wet or dry)? ______

Is your pet strictly:[ ] Indoor[ ] Outdoor[ ] Both

Which of the following applies to your pet? [ ] Leash walked [ ] Fenced Yard [ ] Invisible Fence [ ] Never goes outside [ ] Occasionally goes outside

Do you have other pets?[ ] Cat(s) [ ] Dog(s) [ ] Other ______

Does your pet have any known allergies (to food, medication, vaccines, etc.)?[ ] Yes [ ] No

If yes, please describe:

______

______

Do you need a refill on any medications today (heartworm/flea prevention or others)?

______

(PLEASE CONTINUE TO THE REVERSE SIDE OF THIS PAGE)

By dropping off my pet for treatment,I agree to a Physical Exam by a doctor for a fee of $57.75.

I certify that all information on this form is complete and accurate to the best of my knowledge, and I release Briarcliff Animal Clinic of any liability arising in whole or in part from any information that is not correct.

I understand that if proof of a current rabies vaccine is not available, Briarcliff Animal Clinic will vaccinate my pet against Rabies. Briarcliff Animal Clinic will not examine or treat a pet that is not current on Rabies vaccination.

SIGNATURE______DATE______

**Please leave a phone number where you can be reached in order for the doctor to discuss the treatment plan and provide an estimate for any additional diagnostics or treatment.

I can be reached at( )______-______or ( )______-______

Boarding/Well Drop Off:

CanineFeline [ ] Rabies [ ] Rabies

[ ] DAPP[ ] HCP

[ ] Bordetella[ ] FeLV

[ ] Lepto[ ] Fecal

[ ] Fecal[ ] Clip Nails

[ ] Heartworm Test[ ] Physical Exam

[ ] Bath [ ] Bath

[ ] Clip Nails

[ ] Express Anal Glands

[ ] Ear Cleaning

[ ] Physical Exam

[ ] ProHeart 6 Injection