Drop Off Appointment History and Release

Medical History

Convenient Drop off Appointment Release
Full Name *

First Name Last Name
Pets Name *

Name
Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Please ensure that you are available by phone at ALL times until your pet is released back into your care.
Please enter Diet and Feeding information. *
Check the conditions that apply to your pet. *

Coughing Sneezing Vomiting Diarrhea Eye Discharge Dirty/Itchy Ears Nasal Discharge Limping Skin Issue New or changed lump No concerns
How long has this condition been going on for and with what frequency?
Has your pet experienced this condition in the past?
Check the symptoms that your pet is currently experiencing: *

Not eating Trouble breathing Trouble Defecating Trouble Urinating Weight gain Weight loss Change in behavior Change in activity level No concerns
How long has this symptom been going on for and with what frequency?
Has your pet experienced this symptom in the past?
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.
Has your pet ever had a reaction to vaccinations? *

Yes No Not Sure
Please indicate what preventatives or medications you need a refill of:

Heartgard Frontline Nexgard Revolution
Which preventative care procedures are you approving? (Select all that apply) *

Rabies Vaccine Distemper Vaccine Bordetella Vaccine Influenza Vaccine Lyme Vaccine Leptospirosis Vaccine Feline Leukemia Vaccine Intestinal Parasite (Fecal) Lab test Heartworm/Tick Parasitology (Blood) test Annual Full Organ Function Lab Screening Urinalysis
Are there any other issues/concerns that you would like to discuss at your appointment?
A topical treatment will be applied at the my expense to any pet with evidence of fleas, flea dirt, or ticks. I agree to be responsible for all 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.
Please type in your initials
Authorization: I authorize Mundelein Animal Hospital to do whatever is necessary should an emergency arise. Should be my pet become ill or inure itself, and mah is unable to contact me at the numbers that I have provided, my pet will be treated as deemed necessary by the attending dvm at my own expense.
Clear
Please arrive to your appointment at your scheduled time. Due to our current scheduling restrictions, if you are not able to arrive on time, we may need to reschedule your appointment.
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Medical History