Consent Form

Drop Off Request and Consent Form
Name

First NameLast Name
Best Number

Area CodePhone Number
Next Best Number

Area CodePhone Number
Patient Name
Reason for visit/Requested services
Do you have any concerns you would like the doctor to know about?
Have you given any medications in the last 7 days?
When was last food eaten?
Are bowel movements, urination, appetite and mood normal?
If your patient is here for a medical visit, do you approve bloodwork and/or radiographs if needed:

YesNo
Additional services requested:

Nail trimAnal glands expressedEar cleaningMicrochip
Any other comments:
Agreed upon pickup time:
CPR

In the event that cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of status?

By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.
CPR

AcceptDecline
I acknowledge that payment in full is due at time of service*

Agree
I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Drop Off Request and Consent Form