Drop-Off Form

Drop-Off Form

Thank you for choosing Friendswood Animal Clinic for your pet's medical needs. Often times we accept Drop-Off Appointments with a fully booked schedule and our Doctors will forego their lunch-time to care for your pet, therefore your pet may not be examined until 1:30-2:30p (except for cases where immediate medical attention is necessary). Please understand we will make your pet as comfortable as possible until the Doctor can examine him/her.Please complete the following form to give your pet's Doctor as much information as possible.
Owner's Name*

First Name Last Name
Pet's Name*
Phone Number*

Area Code Phone Number
What is the current problem with your pet?*
How long has this been going on? *

How would you rate your pet's pain level? *

	0	1	2	3	4	5

0 is No pain at all, 5 is Screaming out in pain

How has your pet been eating?*
What kind of food and how much? *
How has your pet been drinking?*
Has there been any vomiting?*

YesNoUnknown
Vomiting for how long? Please make note if you have seen any blood or black, tarry material.
Has there been any diarrhea?*

YesNoUnknown
Diarrhea for how long? Please make note if you have seen any blood or black, tarry material.
How would you characterize your pet's urination?*
Does your pet have an chronic health issues?*

YesNo
Please list all chronic health issues.
Please list all current medications and dosages.*
Does your pet have any known DRUG ALLERGIES or VACCINE REACTIONS?*

YesNoUnknown
Please explain all known DRUG ALLERGIES or VACCINE REACTIONS.
Have all of your pet's recent vaccinations been given by Friendswood Animal Clinic?*

YesNoUnknown
If no, who do we need to contact for vaccination history?
Please include telephone number and name of clinic.
Has your pet gotten into anything abnormal recently (garbage, dead animal, over-the-counter or prescription medications, rat/mouse poison, antifreeze, chocolate, grapes, raisins, onions, garlic, gum, sago palm, etc.)?*

YesNoPossiblyUnknown
How much was eaten and how long ago? If possible, bring the pill bottle, packaging or wrapper with you.
Signature*

Clear
Date of Signature

MonthDay Year
Date
Should be Empty: