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Drop Off Authorization
Owner's Name
Owner's Name
*
First
Last
Patient's Name
*
Who will we be seeing today?
Primary Contact
*
Who should we be calling with updates today?
Primary Contact Phone Number
*
Secondary Contact
If we cannot reach the primary contact, who should we be calling with updates instead?
Secondary Contact Phone Number
Availability Today
*
Please note when you will or will not be available for contact today
Pet Health
Primary Reason for Visit
*
Please describe IN DETAIL why our pet is coming in today (preventive care, illness, injury, etc) and what symptoms your pet is experiencing. Please include details, such as: How long have signs been present? Are they improving, worsening, or staying the same? Any history of this issue? Have any home therapies been attempted? What does the wound/mass look like? Etc.
CATS ONLY
Indoor Only
Indoor + Outdoor
Outdoor Only
If Outdoor Only or Outdoor Combination:
Is your cat supervised when outdoors? Where do they spend their outside time?
What is your pet's diet?
*
Please include brand, variety and flavor (Example: Purina Pro Plan Sensitive Skin and Stomach - Salmon and Rice)
How much given per meal?
*
Examples: Two cups; one 3oz can
How often are they fed?
*
Examples: Twice daily; every 6 hours
Does your pet get treats?
*
Yes
No
What kind of treats do they get? How often?
Please include brand, flavor, amount, and frequency
Does your pet get any table food regularly?
*
Yes
No
What kind of table food do they get, and how often?
*
Examples: Fruits/vegetables, meat, cheese, etc.
May we give your pet treats while they are here today?
*
Yes
No
Do you, or anyone in your household, have a peanut allergy?
*
We sometimes use peanut butter as a treat
Yes
No
Heartworm Prevention
*
Please detail the brand/type of prevention and when the most recent dose was given, or enter "None"
Flea/Tick Prevention
*
Please detail the brand/type of prevention and when the most recent dose was given, or enter "None"
Does your pet get any medications or supplements?
*
Yes
No
Please list all medications/supplements, strength, the form of medication, how much is given, how often, and when their last dose was given
*
Click on the + icon to add more lines.
Name of Medication
Strength (mg or concentration)
Form (tablet, liquid, transdermal, etc)
Amount Given/How Often
Last Dose Given
Any known allergies or sensitivities?
*
Yes
No
If yes, please specify:
*
What are they allergic to? What kind of reaction happens?
Symptoms
Is your pet lethargic?
*
(More tired, less energy than normal)
Yes
No
Unsure/Unknown
How is your pet's appetite?
*
Increased
Decreased
Unchanged
Unsure/Unknown
Comments on appetite?
*
How is your pet's water intake?
*
Increased
Decreased
Unchanged
Unsure/Unknown
Comments on water intake?
*
Is your pet vomiting?
*
Yes
No
Unsure/Unknown
If yes, please describe when it started, how often, and the color/consistency of the vomit.
*
Could your pet have eaten something they should not have?
*
Examples: Blankets, toys, garbage, plants, etc.
Yes
No
Unsure/Unknown
If yes, please specify:
*
Any other possible GI irritants or toxins?
*
Any access to consumables other than their usual pet food? (Examples: New variety of food, new treats, bones, gum, grapes, chocolate, caffeine, human medications, etc.)
Yes
No
Unsure/Unknown
If yes or unsure, please specify:
*
Urination Habits
*
Increased
Decreased
Unchanged
Unsure/Unknown
Comments on urination habits?
*
Diarrhea
*
Yes
No
Unsure/Unknown
Comments on diarrhea?
*
Please specify when it started, how often, the color/consistency, and whether there is any blood or mucous present
Any coughing, gagging or sneezing?
*
Yes
No
Unsure/Unknown
If yes, please specify:
*
Is anything being produced? Please describe material.
Any discharge from the eyes or nose?
*
Yes
No
If yes, please specify:
*
Please describe color, duration of symptoms.
Is your pet lame, limping, or physically injured?
*
Yes
No
If yes, please specify:
*
Please describe where the injury is, when it started, and how it occurred (if known).
Since symptoms started, they have:
*
Worsened
Improved
Remained the same
What, if any, home therapies have been attempted?
Examples: Hot/cold packing, bland diet, OTC medications/topicals/supplements, inducing vomiting, etc.
Any other information you would like us to know?
Consent
*
I am the owner/agent for the described animal. I request and authorize an exam for my pet along with any approved diagnostics and treatments. If recommended for my pet, I understand and accept that when anesthesia and/or sedation is involved there are always inherent risks, including death. I understand payment is due when my pet is discharged. I accept financial responsibility for charges incurred for this pet.
I agree to the terms and conditions above.
Date
*
mm/dd/yyyy
Date Format: MM slash DD slash YYYY
Home
About Us
Our Team
Location and Hours
Forms
Payment and Financing Options
Pet Gallery
New Clients
What To Expect
Take A Tour
Services
Preventive Services
Medical Services
Surgical Services
Exotic Pet Services
Nutritional Counseling
Boarding Services
Additional Services
Pet Health
Pet Health Library
Pet Health Checker
How-To Videos
News
Blog
Refill Request
Appointment Request
Contact Us
