General Drop Off Form Patient Name*Owner's Name* First Last What does your pet need to have done today?*Please check any symptoms you have noticed with your pet bleeding gums breathing problems coughing / sneezing eye / nasal discharge diarrhea loss of balance lethargy lack of appetite limping dehydration shaking head scratching / chewing thirst increased OR decreased urination increased OR decreased weakness vomitingOther symptomHow long have these problems been going on?Please INITIAL any and all treatments and diagnostic procedures we are authorized to performBloodworkRadiographs (X-rays)UrinalysisIV/SQ FluidsBlood Pressure EvaluationCPR / Emergency TreatmentIs your pet currently on ANY medications (**including supplements)?*YesNoPlease list the medications and include dosage (how much & how often)*What type/brand of heartworm preventative are you using?InterceptorSentinelHeartgardAdvantage MultiDate Last GivenWhat type/brand of flea/tick preventative are you using?FrontlineSentinelAdvantageAdvantage MultiDate Last GivenWhat brand of pet food does your pet eat?*Dry or canned*DryCannedHow much and often are they fed?*Does your pet have any known allergies?***We will attempt to perform the above procedures without sedation. However, in some cases it may be necessary to place your pet under light sedation for the comfort of your pet. Your signature below indicates your acceptance of this procedure without additional prior notice.Owner's Signature*I understand the above diagnostic, therapeutic, anesthetic and/or surgical procedures may involve risk of complications, injury or even death, from both known and unknown causes, and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the hospital staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further notice communication with me. I agree to assume financial responsibility for all routine and emergency services rendered.Your signature below constitutes your acknowledgement that (i) you have read and agreed to the above, (ii) the procedure(s) have been explained to your satisfaction and that you have all the information that you desire, (iii) you have had the chance to ask questions, and (iv) you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia (if indicated).** We need the name and number of one person that can be reached and who can make decisions (medical and financial) about the care of your pet. Multiple phone calls affect the prompt care of all of our patients. Legally, this should be the person named on the record as the owner.Owner's Signature*Phone Number*ALL SERVICES RENDERED MUST BE PAID IN FULL AT TIME OF DISCHARGE
