General Medical Drop-off Form

Name*

Client Full NamePet's Name

Date*

Date

Tell us why your pet is here today?

When was the last time your pet ate?

Is your pet vomiting, having diarrhea, coughing, sneezing, feeling lethargic or not eating?*

YesNo

If you answered yes, please describe the frequency of the problem and when it began:

What medication(s) is your pet currently taking and how often? (Please include flea, tick, and/or heartworm medications).
Medication #1 Medication name Frequency How often
Medication #2 Medication name Frequency How often
Medication #3 Medication name Frequency How often
Medication #4 Medication name Frequency How often
Medication #5 Medication name Frequency How often

Please list any specific questions/concerns you have, or procedures you are interested in while your pet is here. (e.g. toe nail trim, vaccine or heartworm test update, etc.)

Are you leaving any personal items with your pet today? If so, please list the items.

Please provide a reliable phone number where you or someone you authorize to make decisions regarding your pet can be directly contacted today. Please leave as many names and associated phone numbers as you would like.

All accounts are to be paid at the time of pick-up. If you, the pet owner, are not the person picking up your pet, do you authorize someone else to do so?
Yes No

If so, please provide the person's name: blanks
If this person is not financially responsible for your pet, please arrange for payment ahead of time.
Thank you!

REDWOOD PET CLINIC STATEMENT:

Please understand that unforeseen conditions may arise during the treatment of your pet. If we are unable to reach you/your representative(s) at any of the above phone number(s), your signature on this form authorizes the performance of such procedures as are deemed necessary by the Veterinarian's professional judgment.

I also authorize the use of appropriate anesthetics and other medications as deemed necessary by the Veterinarian.

Signature of Owner or Authorized Representative*