Drop-Off Examination Form

Name *

First Name Last Name
Patient’s Name *
Phone number where you can be reached *
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Reason for visit: *
Coughing or sneezing? *

Yes No
If yes, for how long? *
Vomiting or diarrhea? *

Yes No
If yes, for how long? *
Eating and drinking normally? *

Yes No
If no, for how long? *
Urinating and defecating normally? *

Yes No
If no, for how long? *
Current diet *
Current medications and/or parasite control *
In addition to an exam, I request the following services *
Your veterinarian will call you to discuss exam findings and recommendations for treatment if needed. We will provide an estimate for additional services.
*

I acknowledge and agree to accept full financial responsibility for the services provided by Bay Animal Hospital from today’s visit.
Date *

Month Day Year
Date
Signature *

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Should be Empty: