Veterinary Drop Off Consent Form

Drop Off Visit Consent Form

Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Pet's Name*

First NameLast Name
Owner/Agent Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Where can we call you at while your pet is at Hilltop Animal Hospital?*

Area CodePhone Number
YesNo
Alternate Phone Number

Area CodePhone Number
YesNo
YesNo
Alternative Contact Name

First NameLast Name
Alternative Contact Phone

Area CodePhone Number
Reason for your pet's visit today?*
Current Diet and Amount:*
Current Medications & Supplements:*
YesNoUnsure
YesNoUnsure
If yes, please describe/provide more information
YesNoUnsure
If yes, please describe/provide more information
Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given:*
What Kind of Heartworm Preventative Do You Use?*
Name of medication - put unknown if not sure
When Was Your Pet's Last Dose of Heartworm Preventative?*
Date Given (Please type N/A if not on a preventative)
What Kind of Flea/Tick Preventative Do You Use?*
Name of medication - put unknown if not sure
When Was Your Pet's Last Dose of Flea/Tick Preventative?*
Date Given (Please type N/A if not on a preventative)
Please note: Hilltop Animal Hospital requires that a treatment be administered at the owner’s expense to any pet with evidence of fleas, flea dirt, or ticks.*
Initial Above
YesNoI Am Not Sure
At Hilltop Animal HospitalI Am Not Sure WhereOther
Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?*
If yes, please tell us more. If no, please note N/A
Is There Anything Else We Should Know About Your Pet?*
If yes, please tell us more. If no, please note N/A
Are there pictures or video that would help us with our exam today?

Browse Files
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Authorizations
I authorize I am the owner/agent of this animal. I have authority to execute this consent. I hereby consent and authorize the performance of the procedures indicated on the medical estimate provided to me verbally and/or written. I understand that the hospital support personnel with be employed as deemed necessary by the veterinarian. The nature of the procedure(s) have been explained to me and no guarantee has been made as to the results or cure. I will not hold Hilltop Animal Hospital, the Doctors or Staff liable for any complications. I have read and understand this authorization and consent. I further understand that payment is due in full at the time services are rendered.*
Initial
Please allow 5-10 minutes for the check in process to be completed. Our staff will review the care plan for your patients visit, associated costs and answer any questions you may have. Thank you!
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Drop Off Visit Consent Form

Authorizations