Patient Drop-off Form

Date

Name

First NameLast Name

Pet's Name:

Best Contact Phone Number

Please enter a valid phone number.

Alternate Contact Phone Number

Please enter a valid phone number.

May we send a text message?

YesNo

Reason for visit today:

This issue began on:

The condition is:

ImprovingWorsening/ProgressingNo changing

Has you pet had any of the following signs (mark all that apply):

If you checked any of the above boxes, please describe the condition and duration of the ailment:

Appetite:

IncreasedNormalDecreased

Thirst:

IncreasedNormalDecreased

Activity level:

IncreasedNormalLethargic

Urination:

AbnormalNormal

Diet (including treats/people food):

When did you pet last eat?

This diet has changed in the past 6 months

YesNo

Please list any medications, supplements or topical treatments your pet has received in the past 6 months and when they were last given:

Is your pet current on vaccines?

YesNoUnsure

Anything else you would like us to know about your pet?

Lab work is essential to evaluate if your pet is showing any underlying problems that may not show up on a physical exam. A CBC looks for signs of anemia and changes in white blood cells and platelets. A Chem 17 Profile checks 17 organ functions and electrolytes and a Chem 10 Profile checks 10 organ functions and electrolytes. If recommended by the doctor, do you authorize lab work?

CBC and Chem 17 + electrolytes ($263.05)CBC and Chem 10 + electrolytes (($221.55)NoI would like to speak with the veterinarian

If recommended by the doctor to aid in diagnosis, do you authorize x-rays?

YesNoI would like to speak with the veterinarian

Sedation is sometimes needed to thoroughly examine, x-ray or treat a patient. If recommended by the veterinarian, do you authorize your pet to be sedated?

YesNoI would like to speak with the veterinarian

Have you received an estimate for today's procedure?

YesNo

Would you like an updated estimate for today's procedure?

YesNo

Emergency Care Authorization

We believe in being well-prepared and would therefore like to know your preferences in the unlikely event of an emergency. Life-threatening complications are extremely rare, but should an event occur, we want to be able to act in accordance with your wishes. Hillside Pet Clinic will make attempts to contact you, but immediate action is essential. Please indicate your preferred emergency response for your pet by choosing one of the options below:

CPR and Emergency Treatment Request

I authorize Hillside Pet Clinic to begin lifesaving treatments on my pet. CPR steps include administering medication, chest compressions, and other emergency measures: $350-$500

Do Not Resuscitate (DNR) Request

Do not use resuscitation methods. I do not wish for CPR or any extraordinary measures to be used on my pet. I understand that in the event of a life-threatening emergency, my pet would not be expected to survive.

Please select one:

I authorize CPR and emergency treatment for my petDo Not Resuscitate (DNR) my pet

The nature and risks of this procedure have been explained to me. I understand that some risks always exist with sedation/anesthesia and/or surgery. I have been encouraged to discuss any concerns I have about the risks with my veterinarian. My signature indicates that my questions have been answered to my satisfaction. In the event that unforeseen complications arise during the procedure, I understand that reasonable efforts will be made to contact me to explain the procedure/treatment and obtain my instructions regarding them. However, if the efforts contacting me are unsuccessful, I authorize Hillside Pet Clinic to proceed as they deem is in the best interest of my pet. I fully understand the risk(s) associated with today's procedure. I will not hold Hillside Pet Clinic, its veterinarians and hospital staff liable for complications that may arise.

I agree

Signature (if sedation is authorized)