Countryside - Authorization for Bath And Treatment

1
Owners Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Pet Name* This field is required.
4
Date of Procedure* This field is required.
Date
Year
Month
Day
5
I expect the hospital to use reasonable precautions to ensure my pet’s safety. If my animal should injure his/herself, escape, fail to eat, become ill, or die, I will not hold Countryside Veterinary Hospital and/or it’s employee’s responsible. As owner (or agent for the owner) of the pet described above, I authorize Countryside Veterinary Hospital to perform any treatment necessary to treat or maintain my pet’s health and well-being if an issue should arise. All pets staying at Countryside must be up to date on Rabies. Dogs must also be up to date on Distemper/Parvo, and Bordetella and Cats must be up to date on FVRCP. I understand that my pet will be given a Capstar ($4.75) that kills fleas for 24 hours upon arrival at Countryside. If live ticks are found on my pet a Flea/Tick Treatment will be applied to my pet at my expense. All pets will be given a Capstar, which kills fleas for 24 hours, upon arrival at Countryside. If ticks are found on my pet a tick treatment will be applied for a fee of $26.91.* This field is required.
Initial
6
Treatment – Doctor Examination
7
Information regarding todays visit* This field is required.Check all that apply
Doctors Exam
Bath
8
Please give a description on the problem/all abnormalities noticed at home* This field is required.
9
If your pet is having an exam please complete the following
Urinating    *
Defecating    *
Eating    *
Drinking    *
10
List all medications your pet is currently taking* This field is required.
11
Do you need to purchase Heartworm Prevention* This field is required.
Yes
No
12
* This field is required.
Intercepter Plus
Trifexis
ProHeart Injection 6mo
None
Brand
1 months
2 months
3 months
4 months
5 months
6 months
12 months
Qty
13
Do you need to purchase Flea/Tick Prevention* This field is required.
Yes
No
14
* This field is required.
Bravecto 3mo Tab Canine
Credelio 1mo Tab Canine
Revolution Plus Feline
None
Brand
12 Doses
6 Doses
3 Doses
1 Dose
Doses
15
Please list all previously known diagnoses/health conditions* This field is required.
16
Telephone number where owner/agent can be reached* This field is required.
Area Code
Phone Number
17
Signature* This field is required.
Clear
18
Date* This field is required.
Date
Year
Month
Day
Should be Empty: