HVH Drop Off Consent Form, fillable

HILLSIDE VETERINARY HOSPITAL

Drop Off Consent Form, Fillable
191 Augustine Avenue Suite 100, Charles Town, WV 25414 // (304) 728-2203

www.hillsideveterinaryhosptial.com
Drop Off Consent Form

Drop Off's will be scheduled with an "arrival time", this is not an appointment, and your pet will be admitted to the hospital for the day. Our doctors look at drop offs in between scheduled appointments, with emergencies taking precedence. Our staff will be in touch once your pet has been examined. Please plan accordingly. In order for us to best understand why your pet is being dropped off, please fill out this form in its entirety, prior to your pet's visit. *Please note - we cannot guarantee which doctor will be seeing your pet while here, as we examine pets in the order in which they are dropped off*
Client Name:
Pet Name:
Patient Species:
Canine (dog), Feline (cat)
Breed:
Sex:
Male, Female, or Unknown
Color:
Birth Date:

Month Day Year
Date
Client Address:
street, city, state, zip
Telephone:
(123)-456-7890
Email:
example@example.com
What is the main reason for your pet's visit today? Please provide as much detail as possible: *
How long has this problem been going on?
Has it gotten better, worse, or same?
Have you provided any treatment(s) at home?
Has your pet ever had a reaction to any med(s)?
Is your pet on Heartworm medication?

Yes No
If yes, what kind - and when was last dose?
Examples: Heartgard, Interceptor, Revolution, Sentinel
Is your pet on Flea/Tick Medication?

Yes No
If yes, what kind - and what was last dose?
Examples: Bravecto, Capstar, Credelio, Frontline, Revolution, Sentinel
What brand of food does your pet eat?
How much?
Cats:

Indoor Only Outdoor Only Indoor/Outdoor
Please check any symptoms your pet is experiencing:
Vomiting Shaking Head Scratching Diarrhea Constipation Coughing Blood in stool Lack of appetite Lethargy Lump(s) - location Sneezing Seizures Limping Increased drinking or urination
If we are checking lumps - give location/description
If limping - which leg(s)?
In order to assist your pet as quickly as possible, do you give permission to do the following if deemed necessary by the Veterinarian?

Labwork X-rays Sedation/Anesthesia
Please indicate if/which vaccinations/tests, or services, you would like us to perform today:

Please Note: WV state law requires a current Rabies vaccination on all pets. If your pet is not current, we are legally obligated to vaccinate for Rabies while here today.
Rabies (dog) $25 DHPP (dog) $20-26 Lyme (dog) $38 Bordetella (dog) $25 Canine Influenza $52 Leptospirosis (dog) $25 Heartworm/Lyme/Ehr/Ana snap test (dog) $45 Rabies (cat) $25 4in1/FVRCP vacc (cat) $20-$26 Leukemia vacc (cat) $30 Leukemia/FIV test (cat) $50 Nail Trim $15 Anal Sac Expression $18
AUTHORIZATION: I verify I am the owner (or Authorized agent) of the above named pet and authorize the above procedure to be performed. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet if it stays overnight (pets needing special care may be referred to a 24 hour hospital).
Best Phone Number to reach you today: *
May we text?

Yes No
Owner/Agent Name (print):
Signature: *

Clear
Date:

Month Day Year
Date
Any medication your pet is on?
Last dose:
Should be Empty:

HILLSIDE VETERINARY HOSPITAL

Drop Off Consent Form