Drop Off Form - Original

Name*

First NameLast Name

Pet's Name*

The next 4 questions below are asked before every appointment regarding your pet's most recent visit in a veterinary hospital, and behavior changes that have come up that may help us give your pet a Fear Free experience for your pet with us today!

How did your pet feel after their most recent visit with a veterinarian?

How well has your pet been traveling in the car?

Does your pet have any fear, stress or anxiety around other pets?

How does your pet do meeting strangers?

What medications is your pet currently taking?

List all including flea, tick and heartworm prevention.

Have you discussed and reviewed the itemized treatment plan containing the cost for today's services with a member of our staff

YesNo, I would like to speak with one of your team members.

Do you agree with the services that are listed on the treatment plan?*

YesNo, I would like to speak with one of your team members.

Does your pet need anything else today that is not listed in the plan?*

YesNo

What else can we do for your pet today?

I understand that at the time of my drop off I will be required to provide a deposit in the amount of 50% of the planned treatment plan.*

Yes, I am aware that I will need to provide a deposit at the time of drop off.

I understand that at the remaining 50% will be due at the time of pickup.*

Yes, I am aware that payment in full is required when I pickup my pet.

Have there been any changes with your pet since your last visit, or is there anything that you would like us to know about?*

YesNo

Has your pet had any food or medication today?

YesNo

Please list how much food, and medication and times below.

What else would you like us to know?

Please make sure your app is downloaded and up to date and that you are a registered user. This is the best way to communicate with us while your pet in our hospital. Please make sure your notifications are turned on so you don't miss any messages! And feel free to send us a message to check on your pet anytime!

If you do not have our app, just click here to go to our website, and simply click "Our App" at the top! Or just search ACVH in your app store.

Depending on what we have planned for your pet today, our team may still need to review your treatment plan with you, or you may receive additional forms prior to, or at the time of your drop off.

If your pet is receiving an anesthesia procedure today, please select yes below and review and sign the anesthestic consent form.

Is your pet receiving an anesthetic procedure today?*

YesNo

At American Canyon Veterinary Hospital we only provide quality anesthesthics, with the highest standards for our anesthestic monitoring equipment and personel, while having a skilled Veterinary Assistant soley dedicated to monitoring your patient while under anesthesia. However even with the best medical care, there are always risks with anesthesia. We do everything we can to minimize and prevent these risks by requiring preoperative bloodwork, IV fluids, and additional therapies depending on your pet's condition.

Please review the terms below. If you have any questions please send us a chat message or give us a call inside the clinic at 707-644-2284

I understand that the veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff has my permission to proceed with life sustaining procedures. I also understand that I will be responsible for any and all costs associated with those procedures.*

I agreeDisagree, in the event of an anesthetic complication, I do not authorize American Canyon Veterinary Hospital to perform life saving measures without my permission, and subsequently I will not hold American Canyon Veterinary Hospital responsible for the outcome of this circumstance.

I understand that I need to be available throughout the day of my pet's scheduled procedure, and unless otherwise discussed, that the app will be the main form of communication on the day of my pet's procedure.*

Agree

I understand that American Canyon Veterinary Hospital does not offer 24 hour care, and I will be available to pickup my pet after the procedure at the time discussed with a team member.*

Agree

Is your pet having a dental procedure today?

YesNo

Please be advised that your pet may receive extractions during this procedure. We have no way of knowing exactly what we will find until we have your pet anesthetized and taken full mouth radiographs, and at that point our DVM will determine whether or not extractions need to be made. Rest assured that our DVM will never extract teeth unless medically necessary. It is our policy that we will not anesthetize a patient for this procedure without your consent to possible extractions, and your understanding that that we will not contact you during the procedure for approval prior to the extractions. If you would like to speak with someone further on this matter please let our CSR know.

I give my consent to dental extractions if medically necessary, and I understand that I will not be contacted during the procedure.

My signature below certifies that I, the owner of the pet identified above, authorize the staff at American Canyon Veterinary Hospital to perform the planned procedure(s), service(s) or treatments(s) that are listed on my treatment plan. I have discussed anesthestic options that are available to my pet with a team member, and I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.

Signature*

Patient Hospitalization and Procedure Consent Form