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
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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 ($6.81) 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. 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.
Please Select
Please Select
Interceptor Plus
Credelio Quattro
ProHeart Injection (6 mo)
None
Brand
Please Select
Please Select
1 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.
Please Select
Please Select
Bravecto 3mo Tab Canine
Credelio 1mo Tab Canine
Credelio Quattro 1mo Tab
Revolution Plus Feline
None
Brand
Please Select
Please Select
12 Doses
6 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
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
Should be Empty: