River Road - Drop-Off Consent Form

1
Your Info:* This field is required.
Pet's Name
Your Full Name
Appointment Date
2
Your contact details:
Best Contact Number
Emergency Contact Number
Email
Call
Text
Email
What is the best way to reach you?
Any availability limitations?
3
Appointment Details
What is your pet being admitted for?
Any doctor/No preference
Any doctor/no preference
Dr. Ben Brignac
Dr. Jen Mains
(Do not select - Dr. Wheeler is out of the office on maternity leave until ~February 2023)
Which doctor would you like to perform these services?
4
Has your pet eaten after 10:00 PM?***Note: This is in reference to the night before the scheduled appointment.
Yes
No
5
Has your pet had any medication recently?
Yes
No
6
If yes, please provide to following: Drug name, strength, and amount/frequency given.***Note: Please give all morning medications before drop-off unless otherwise instructed by doctor.
Huge
Large
Normal
Small
Ok
Ok
7
Drop off time is between 8am-9am. If you would like to request an earlier or later time, please contact us directly.
I understand and agree.
8
Because this is a drop off appointment, please understand that your pet will be seen in between previously scheduled appointments during the day. When your pet is ready, we will contact you by your contact method listed in this form. Your pet will be ready to go by 5:30pm.
I understand and agree.
9
I, the undersigned owner or agent of the aforementioned pet, certify that I am at least eighteen years of age and authorize the veterinarian(s) at River Road Veterinary Hospital to perform the stated services. I agree to meet all the costs of the consultation before or at time of pickup.
I understand and agree.
10
Signature* This field is required.By signing below, I state that I have read and understood the drop off consent form in its entirety.
Clear
Should be Empty: