Drop Off Information Sheet

Owner:

Pet:

Date:

Reason for drop off:

How long has your pet had symptoms?

When was last meal?

Please list all symptoms here:

Any Medications/Heartworm Prevention given. Please list & when given:

Last vaccinations given/where/when:

If not current, an Exam & Required Vaccinations WILL be given!

Any chronic/ongoing/additional information that may be helpful. (Ears, skin, etc.?)

* In the event it is determined that your pet(s) needs additional treatment, we will call you at the numbers indicated. If we are unable to reach you, we will follow the treatment option below. Choose an option:

I trust your decision to perform any testing, treatment, or x-rays as deemed necessary for my pet’s health.

Perform only the treatment authorized at time of drop off.

Please Note: It is difficult to give an estimate of charges when a patient is dropped off for treatment/emergency services. Please wait to discuss fees after the veterinarian has examined your pet and a discharge appt. has been made.

NOTICE OF RISK WITH ANESTHESIA

Any veterinary service that required anesthesia poses a potential health risk to your pet. A current CBC/Chemistry Panel may identify some potential risk factors and/or ensure that your pet is in a lower risk category. Please choose one of the following:

Routine (Under 2yrs) $45/$95

Intermediate (2-6 yrs) $70/$110

Comprehensive (7+yrs) $115/$135

MICROCHIPPING $40.00

-OR-

I decline the recommended WELLNESS CHECK at this time and request that you proceed with anesthesia. I understand that there is always a potential risk of death associated with the use of anesthesia

Additional Comments:

Please list ALL phone numbers or pagers where you can be reached TODAY.

I accept the conditions outlined in this Surgery Treatment/Anesthesia Release Form.

I do not accept the conditions outlined in this Surgery Treatment/Anesthesia Release Form.

* Indicates Response Required

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