Drop Off Form (Camp Bow Wow Camper)

Today's Date*

MonthDay Year
Date of Appointment*

MonthDay Year
Your Name*
Pet Name*
Email*
Cell Phone (preferred)*
Please make sure this is the number for whomever is authorized to make medical and financial decisions for the patient.
Secondary Phone Number

Area Code Phone Number
Reason for Visit (check all that apply)

Preventive CareIllnessInjry
Are there any concerns for: (check all that apply)

EatingExcessive SleepingItching/ScratchingShaking HeadSkin Masses/LesionsDrinkingWeight LossDifficulty RisingVomitingUrination IssuesBad BreathWeight GainScootingDiarrheaBehavioral Problem
Please give history on concerns listed above*
Has your pet ever had an adverse reaction to any medication(s), vaccine(s), or procedure(s)?*

NoYes
If yes, please describe
Is your pet taking any medications?*

NoYes
Is yes, what?
Do you need medication refills? Please enter what medications need to be refilled. (Ex: Apoquel, Trazadone, etc )
Which vaccines does your pet need to have administered during today's visit :*

BordetellaLeptospirosisDHPPRabiesLymeCanine InfluenzaNo vaccines to be administered during visit
Please indicate if you would like your pet to receive pre-medication prior to vaccinations. Although reactions to vaccines are relatively low, there is always a possibility for your pet to react whether or not they had symptoms or issues in the past. We offer a diphenhydramine injection prior to vaccination(s) to minimize the chance of reaction. If your pet has had any reactions in the past, then we strongly recommend this injection. Other medications or treatments may be needed if your pet has a vaccine reaction. *

Yes (additional charge)No
What other preventive care services does your pet require during today's visit :

Annual heartworm and tick borne disease screeningAnnual intestinal parasite screeningAnnual canine health screening (full panel bloodwork)
Would you like a Microchip implanted?*

YesNoAlready microchipped
How many doses of heartworm prevention does your pet need refilled at today's visit?*

6 doses of Sentinel6 doses of Simparica Trio12 doses of Sentinel12 doses of Simparica Trio1- 6 month heartworm prevention injection (Proheart 6)1-12 month heartworm prevention injection (Proheart 12)I decline to purchase any prevention at today's visit.My preferred brand is not one listed, please send me a link to your online pharmacy to purchase my refill.
How many doses of flea/tick prevention does your pet need refilled at today's visit?*

6 doses of Simparica6 doses of Simparica Trio12 doses of Simparica12 doses of Simparica TrioI decline to purchase any prevention at today's visit.My preferred brand is not one listed, please send me a link to your online pharmacy to purchase my refill.
Does your pet need a nail trim during today's visit?*

NoYes (additional charge)
Does your pet need an anal sac expression during today's visit?*

NoYes (additional charge)
Please confirm payment option has been arranged prior to appointment :*

Credit Card (card must be stored on file PRIOR to appointment
All fees are due at the time services are rendered. I assume responsibility for all charges incurred in the care of my/our animal(s). I also understand that these charges will be paid in full at the time of release and that a deposit may be required for surgical treatment. Any unpaid balance will be sent to collections, for which I agree to reimburse Advanced PetCare of Oakland the fees of any collection agency, which may be based on a percentage of 32% of the total amount plus 7% interest, as well as all costs and expenses, including reasonable attorney's fees we incur in such collection efforts.*

I agree to the above terms & conditions *
Signature

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