Docton Animal Clinic Drop Off Form

Name as listed on your account

First NameLast Name

Pet's Name

I realize the doctor may need to reach me throughout the day, please call me at

Please enter a valid phone number.

In case of emergency and you are unable to contact me, please call

Please enter a valid phone number.

I am leaving my pet in the care of Docton Animal Clinic. In my absence I authorize Docton Animal Clinic and their veterinarians to provide care for my pet named above. All procedure charges for today's care will be paid at the time I pick up pet later today.

Initial:

Known medical problems, previously diagnosed medical issue:

Current medications daily medications. Last dose was given when?

Current Flea Prevention? Date of last dose:

Current Heartworm/Intestional worm Prevention? Date of last dose:

Current Diet (treats included), Amount, Time of last meal:

Is he/she eating normally?

When was test's last normal bowel movement?

Has pet had any vomiting or diarrhea? If so when did it start?

Has pet been experiencing increased urination? If so when did it start?

Has your pet experienced any seizures or seizure like activity? If so how many episodes and how long did they last?

Has your pet experienced any coughing and/or sneezing? When did it start?

Any known allergies to medication?

Symptoms/Current Complaint/Why is pet here today? How long has this been going on?

Signature

Date

Drop Off Care Form