Patient Drop-Off Form

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Please fill out this form each time your pet has a scheduled drop-off appointment. If you have appointments for more than one pet, please submit a separate form for each pet.
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Owner's Name* This field is required.
First Name
Last Name
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Pet's Name* This field is required.
Pet's Name
Owner's Last Name
4
E-mail* This field is required.
5
Owner's Phone Number (where we can reach you while your pet is being examined)* This field is required.
Area Code
Phone Number
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Is someone else transporting your pet to the appointment?* This field is required.
YESNO
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Transport/Contact Person's Name* This field is required.
First Name
Last Name
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Transport/Contact Person's Relationship to Owner:* This field is required.
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Transport/Contact Person's Phone Number (where we can reach them while your pet is being examined)* This field is required.
Area Code
Phone Number
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Scheduled Appointment Date * This field is required.
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Describe the current problem(s): please note duration, severity, character, etc., and services requested.
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Ok
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Does your pet have any significant previous or ongoing medical problems?
YESNO
13
List any significant medical problems:
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Ok
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Is your pet taking any medications or supplements?
YESNO
15
List any medications your pet is taking (dose & frequency):
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History: Has your pet experienced any recent changes with the following:* This field is required.
No recent changes
Appetite
Thirst
Activity Level
Coughing
Sneezing
Vomiting
Defecation
Urination
Itching
Fur/Skin Problems
Head shaking/painful ears
Body weight over last 6 months
Lameness or stiffness
Bad breath/mouth discomfort
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Please describe appetite changes (Example: increased/decreased, etc.)* This field is required.
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Please describe thirst changes (Example: increased/decreased, etc.)* This field is required.
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Please describe activity level changes (Example: increased/decreased, etc.)* This field is required.
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Please describe any coughing, when it started, and if your pet has been around other pets recently. (Example: dry coughing started yesterday after visiting the pet store last week.)* This field is required.
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Please describe any sneezing, when it started, and if your pet may have been around other pets recently. (Example: sneezing started yesterday after visiting the dog park last week.)* This field is required.
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Please describe any vomiting, when it started, and if your pet may have been exposed another pet who is ill, ate anything unusual (extra treats, table scraps, new brand of food), or if your pet may have ingested any non-food items such as a plastic bag or a rock. (Example: vomiting started yesterday after chewing up a plastic toy)* This field is required.
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Please describe any defecation issues, how long since the last bowel movement and what is the stool consistency - diarrhea or constipation? (Example: My dog's diarrhea started this morning after eating the cat's food yesterday).* This field is required.
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Please describe any urination issues, increased or decreased frequency, having accidents in the home, etc. (Example: My cat has been urinating outside of her litter box for two days.)* This field is required.
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Ok
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Please describe any recent itching or scratching behavior, seasonal allergies, or fleas observed on your pet. (Example: my dog has been chewing his toes for a week and gets itchy every summer)* This field is required.
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Ok
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Please describe any fur or skin problems your pet has experienced recently, including hair loss, coat color changes, dry flakey skin, hot spots, sores, skin growths, abscesses, or other skin/coat issues? (Example: my dog has been scratching at his invisible fence collar and the skin is raw and red.)* This field is required.
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Ok
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Please describe any head shaking or painful ears, including when the problem started, left/right/both ears, and if this is an ongoing issue for your pet. (my dog has been shaking her head and crying if we touch her right ear. This is a new issue for her)* This field is required.
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Please describe any body weight changes over the past six months such as noticeable weight gain or loss. (Example: my cat seems to be losing weight over the past few months.)* This field is required.
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Please describe any lameness or stiffness your pet has experienced recently, including approximate onset, severity, and which body parts or limbs are affected. (Example: my dog will not bear weight on his back left leg after he fell running up the stairs.)* This field is required.
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Please describe any observed bad breath or mouth discomfort your pet has been experiencing including timeframe, appetite changes, oral swelling, broken or cracked teeth, excessive tartar, growths or sores. (Example: My cat has terrible breath and has been drooling. He will only eat wet food.)* This field is required.
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Does your pet use heartworm preventative?* This field is required.
YESNO
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When was heartworm preventative last given?* This field is required.
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Does your pet use flea/tick preventative* This field is required.
YESNO
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When was flea/tick preventative last applied?* This field is required.
35
Does your pet primarily live:
Inside
Outside
Both
36
Has your pet ever shown aggression toward people or other animals?* This field is required.
No
Yes
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If yes, please explain:* This field is required.
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In using this drop-off form, I understand that IT IS ESSENTIAL I AM AVAILABLE BY PHONE (not voicemail) so that the doctor can best help my pet and me. If I am not available, I understand that the doctor will proceed as directed below.* This field is required.
Treat as needed (no further permission required)
Wait to contact me prior to treatment for SERIOUS medical problems only
Wait to contact me prior to ANY medical treatment
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Who will be picking up your pet?* This field is required.
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Expected pickup time:* This field is required.
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I, the undersigned, do hereby give my consent for the doctors of Hudson Veterinary Hospital to treat, prescribe, or operate on my pet named above. They are to use all reasonable precautions against illness, injury, or escape of my pet, but they will not be held liable or responsible in any manner what so ever, under any circumstances, on account of the care, treatment, or safe keeping of my pet, as it is thoroughly understood that I assume all risks. Should the circumstance arise that my pet remains unclaimed after the date which I have stated as the pick-up date, I understand that written notice will be mailed to the address on file. Seven days after I understand that such action will not relieve me from paying all costs of your service and the use of your hospital, including the cost of the boarding service. Please type your name to electronically sign this form.* This field is required.
First Name
Last Name
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Please verify that you are human* This field is required.
Should be Empty: