Patient Drop Off Form

Date

Name*

First NameLast Name

Email*

example@example.com

Cell Phone Number*

Area CodePhone Number

Patient Name*

Species*

DogCat

Sex*

Female - IntactFemale - spayedMale - intactMale - neutered

Please Describe the Procedure we are performing Today*

Please Scroll to the bottom of this form if you have already talked to the staff or doctor about your pet's symptoms and history.

Please Describe any Relevant Medical Problems or Symptoms

Please list all medications your pet is taking

Do you need any refills

Please Tell us about your pet's diet

Appetite

Normal / No ChangeIncreasedDecreased

Water Consumption

Normal / No ChangeIncreasedDecreased

Weight

No ChangeIncreasedDecreased

Is your pet experiencing the following?

How long have the symptoms noted above been going on?

In some cases it might be necessary to sedate your pet to facilitate safe and stress-free treatment, diagnostics or procedures. If necessary, do you give permission to sedate your pet?*

YESNOCall Me First

First Person to Contact *

First NameLast Name

Phone Number*

Area CodePhone Number

Second Person to Contact*

First NameLast Name

Phone Number*

Area CodePhone Number

Is there anything else you would like us to know?

I, the undersigned, hereby confirm that I am the legal owner / agent of the animal described above and I am authorizing the staff of Hilton Animal Hospital to administer treatment, perform diagnostic and prophylactic procedures, and care for my pet as deemed necessary by the attending veterinarian.

I acknowledge that no assurance or guarantee has been made of the results of treatments, procedures, or surgery. I am aware that every surgical procedure, treatment, and anesthesia, even performed on a healthy animal, carries a certain amount of risk and possibilities of complications.

Hilton Animal Hospital or its staff will not be held responsible in any manner whatever or any circumstance, on account of the care, treatment, or safe keeping of the animal described above or otherwise in connection therewith. I hereby authorize the staff of Hilton Animal Hospital to perform any reasonable treatment, procedure and care for my pet as deemed necessary by the attending veterinarian.

The cost and charges of the procedure listed above has been disclosed to me, to my satisfaction. I acknowledge that I will bare full financial responsibility for any and all costs incurred for the treatment and care of my pet, and I am aware that all outstanding accounts are payable in full after services are rendered.

I have read and understood the statement above.

Signature*

sign with mouse / sylus or finger

Patient Drop Off Form

Contact Information