Drop Off Consent Form

Patient History Drop Off Consent Form

Please fill out this patient history in it's entirety so that we can accurately access your pet's condition.
Owner's Name *

First NameLast Name
Pet's Name*

First NameMale or Female
Approximate Age*
Breed *
Coloring*
Please describe your pet's collar, leash, and carrier if applicable. *
It is imperitive that we be able to reach you in a timely manner while your pet is in our hospital today. The phone number entered below should be one where we can contact you at any time. To ensure the best care possible please be available and free to talk or respond to Pet Desk App messaging when contacted.
Where can we reach you while your pet is here?*

Area CodePhone Number
YesNo
YesNo
What is the reason for your pet's visit today? *
This issue began on:*
Date
NewContinuing (stable/unchanging)Worsening

How disruptive or troublesome do you feel this issue is to your pet?

	1	2	3	4	5

1 is Worst, 5 is Best

CoughingSneezingVomitingDiarrhea
Color of any discharge*
Texture
Frequency*
Consistancy*
Duration*
YesNo
YesNoI'm not sure
YesNoI'm not sure
New lumps or bumpsBehavior changesChanges in mobility
Please Describe Changes*
Location of Lumps/Bumps*
When Did You Notice Them?*
Any Discharge or Odor from Bumps?*
If increased or decreased, please provide more information:*
When did you notice a change? *
NormalIncreasedDecreased
NormalIncreasedDecreased
If increased or decreased, please provide more information:*
When did you notice a change in your pet's health? Please explain.
NormalIncreasedDecreased/Easily Fatigued/Lethargic
If increased or decreased, please provide more information:*
NormalIncreasedDecreased
Color*
Amount*
Frequency*
Duration of Abnormal Urination*
If your pet is a cat, you noted any changes in litter box usage? Have they defecated or urinated outside of the litter box over the past 6 months?
Wet food onlyDry food onlyWet and Dry MixturePeople FoodRaw DietHome Cooked DietOther
Brand of Pet Food*
If prescription diet, what formulation?*
How often Is your pet fed?*
How much Is your pet fed?*
In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)*
YesNoI am not sure
Eaten garbageIngested toxins (rat bait, ant bait, other known toxic substances)Ingested human medications or illicit drugs.Ingested MarijuanaEaten toys (part of toys missing, chewed up etc.)Eaten grain free diet for any period of timeIngested animal medications not intended for them or at higher doses than intended?Eaten articles of clothing such as socks, underwear, etc.Eaten hair ties, barrettes, rubberbands, etcEaten an outdoor animal such as rabbit, mice, bird, etcNone of the above are a possibility.Other
If any of the above items are true, please tell us more:*
Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:*
When was your pet's last dose of heartworm peventative?*
Date Given (Please type N/A if not on a preventative)
What kind of heartworm preventative do you use?*
Name of medication - put unknown if not sure
When was your pet's last dose of flea/tick preventative?*
Date Given (Please type N/A if not on a preventative)
What kind of flea/tick preventative do you use?*
Name of medication - put unknown if not sure
Indoor OnlyMostly Indoor but Rarely to Occasionally Spends Time OutdoorsIndoor/OutdoorOutdoor OnlyOutdoor During Day/Inside At NightOther
YesNoFarm Animals
Please tell us about the other pets in your home*
Visit the dog parkGet Groomed RegularlyCompete in Dog/Cat ShowsAttend Obedience TrainingAttend Agility/Dock Diving/Search and Rescue programs etc.BoardAttend Doggie DaycareTravel with you outside of Pennsylvania?Travel with you inside the state of Pennsylvania?
YesNoI Am Not Sure
At Aardvark Animal HospitalI Am Not SureOther
YesNoI Am Not Sure
YesNoI don't know
DogCatOutdoor AnimalOther
Does your pet have known health concerns and/or chronic disease or conditions?*
If yes, please tell us more. If no, please note N/A
Is there anything else we should know about your pet?*
If yes, please tell us more. If no, please note N/A
Are there pictures or video that would help us with our exam today?

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Is there anything else you would like to discuss today?*
YesNo
Initial*
Authorization To Treat

Please initial each line, sign and date.
As owner or duly authorized agent of the owner, of the above named animal, I hereby consent that all the above information is correct and I authorize Aardvark Animal Hospital LLC staff to receive, prescribe, treat, or anesthetize or operate on my animal.*
Initial
Our office is to use all responsible precautions against injury, escape, or demise but will not be held liable or responsible in any manner regarding the care, treatment, or safe keeping of the animal. I understand that I am assuming all risks involved in care and treatment of this animal. I consent to administration of anesthesia as deemed necessary by the doctor. I acknowledge that risks and the possibility of complication exist in any surgical or medical treatment. *
Initial
All animals must be picked up within three (3) days of the specific release date. Five (5) days after such, the animal will be considered abandoned and will become the property of Aardvark Animal Hospital. It is understood that abandonment does not relieve me from the responsibility of payment for services rendered, including the cost of boarding. *
Initial
I agree that in the case of non-payment, a reasonable fee per month will be charged. All collection and attorney fees necessary to collect this debt will be born to me. *
Initial
I understand that surgery fees or in-house treatment fees do not cover the cost of medications to go home. I understand that I will be responsible for the cost of medications to go home with my pet. *
Initial
I will receive a treatment plan which will include the estimated costs of any procedures on this given day. I acknowledge the scope of this treatment plan and I understand that actual charges may differ depending on my pet's medical needs and response to treatment. Aardvark Animal Hospital LLC agrees to make every reasonable effort to stay within the fees set forth in my treatment plan and to contact me should any additional charges be deemed necessary. I agree to pay in full at the time my pet is discharged and, in the case of nonpayment, a reasonable fee per month will be charged. All collection and attorney fees necessary to collect this debt will be born to me. *
Initial
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Patient History Drop Off Consent Form

Authorization To Treat