Talega AH - Drop Off Consent Form

1
* This field is required.
Name
Phone number
Email
Pet Name
2
Your pet Pet's Name * is being dropped off today for an examination by one of our doctors.
3
Please provide a detailed description of the presenting problem(s) to aid in the doctor's examination, including symptoms, and duration.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
4
Please let us know how your pet is doing in the following areas (select all that apply)* This field is required.
Coughing
Sneezing
Vomiting
Diarrhea
None
Is your pet showing any of these symptoms?
Please Select
Please Select
Excessive
Normal
Decreased
How is your pet's appetite?
Please Select
Please Select
Excessive
Normal
Decreased
How is your pet's water intake?
Please Select
Please Select
Normal
Lethargic
Hyper
How is your pet's energy level?
What is your pet's current diet? When did your pet last eat?
5
Please explain the symptoms your pet is experiencing.
6
Do we have permission to add your pet's photo and/or video to our social media pages? * This field is required.
YESNO
7
Please let us know if your pet is currently taking any medications:* This field is required.
Medication
How much do you give?
When did you give it last?
8
I authorize Talega Animal Hospital to examine my pet and, at the discretion of doctor, run any necessary lab tests (such as blood work, sedation, urine test, fecal test and/or x-rays) and to proceed with any treatment beyond the exam and lab tests without an estimate and my permission.* This field is required.
YESCALL WITH ESTIMATE
9
Signature* This field is required.
Clear
10
Phone Number* This field is required.
Area Code
Phone Number
Should be Empty: