Drop-Off Examination Form

Name*

First NameLast 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?*

YesNo

If yes, for how long?*

Vomiting or diarrhea?*

YesNo

If yes, for how long?*

Eating and drinking normally?*

YesNo

If no, for how long?*

Urinating and defecating normally?*

YesNo

If no, for how long?*

Current diet*

Current medications and/or parasite control and date last given*

In addition to an exam, I request the following services*

In the event of an emergency, Bay Animal Hospital veterinarians will perform CPR/life-saving measures while we attempt to reach you.*

Perform CPRDo Not Perform CPR

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*

Date

Signature*

Clear