Drop Off Consent form

Drop Off Consent form
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Pet's Name*
Type of pet*

CatDogHorseOther
Have you noticed your pet having any of the following problems? Please check all that apply.
LethargyDecreased appetiteDifficultly eating/drinkingVomitingDiarrheaConstipationStraining to urinateIncreased thirst/water intakeChange in behaviorPantingGaggingCoughingShaking headItching/ScratchingLimpingWeaknessStiffnessPainHair LossVision LossWeight LossWeight gainScootingWatery eyes
Please describe any other issues
Please give more details about the selected symptoms, specifying location if applicable*
When did these symptoms start*

MonthDayYear
Date
Is your pet on any medications or supplements?*

YesNo
If yes, please specify and what time your pet received it's last dose
Environment: Please indicate whether your pet lives:*

Inside ONLYOutside ONLYBOTH
FINANCIAL CONSENT
Please note that every Drop off will be a minimum of $62 office visit due at time of service *Urgent Care visits are $112
Please select ONE option to increase the efficiency in which your pet is treated*

Do NOT perform any treatments beyond the office visit, until I have been contactedI give SVS permission to examine/treat the above patient for the listed reasons. If treatments are warranted, please do not exceed the following amount
I authorize treatment of my pet up to the following amount:

$300$400$600Treat as needed
If we have questions/need authorization to perform tests, and cannot reach you, we will wait until you call us to finish your pet’s exam and treatment.
Is there someone else we should call for treatment/financial decision approval?*

YesNo
Name Phone Number
I understand that all services are due at the time of discharge, and that SVS does NOT offer primary payment plans. Failure to pay at discharge is theft of services. *
Inital
I request Sagehills Veterinary Services to examine my pet and to provide the following services if my pet is deemed healthy (at additional charge):
Canine Vaccines/Treatments

DH(L)PP (Distemper/Parvo)RabiesBordetellaRattlesnake VaccineExpress anal glandsDewormClean/treat earsToe nail trimOther
Feline Vaccines/Treatments

FVRCP (Distemper)RabiesLeukemiaFeLV/FIV testingToe nail trimDewormClean/treat earsOther
- Please call us around 3pm to check on the status of your pet’s exam – drop-off exams are worked in between surgeries and appointments.

- In cases of emergencies, where there is an immediate threat to the well-being of your pet and we are unable to contact you, our Veterinarians will take the necessary steps to stabilize your pet and alleviate pain until we are able to contact you.

- Please note that all drop offs are triaged at time of drop off, but their examination may not take place until later in the day. We can assure you that your pet will be seen, but completion of treatment may occur after business hours (no additional charges).
Please note that payment is expected at the time of service. By signing below, you agree to the above terms and conditions and authorize Sagehills Veterinary Services to examine my pet.
Signature*

Clear
Date*

MonthDayYear
Date
Best Phone number to reach you today*

Area CodePhone Number
Should be Empty:

Drop Off Consent form

Have you noticed your pet having any of the following problems? Please check all that apply.

FINANCIAL CONSENT