Business Account Patient Drop Off Appointment Form

Date of drop off

Date

Business Name

Your name

First NameLast Name

Your Phone Number

Please enter a valid phone number.

Animals Name

First NameLast Name

Species

If you selected other from above, please indicate the animals species below.

Services to be performed during today's visit

Is the animal on any medications? If so please list name, dosage, and frequency here. *PLEASE INDICATE THE LAST TIME THESE MEDICATIONS WERE RECEIVED*

Is your pet eating normally? If no, please describe in detail below

When did your pet last eat?

Has there been a change in diet? If so when?

Does your pet have any allergies or food allergies? If so, list them here. If none, write none.

Is your pet drinking normally? If no, please describe in detail below

When did your pet last drink?

Please list any concerns that you have in as much detail as possible.

Name of the person to contact regarding the pet

First NameLast Name

Phone Number for contact listed above

Please enter a valid phone number.

The following is a routine patient admission release form that will outline the proceedings of the animal's stay with us today.

All pets being admitted to the hospital must be up to date on any necessary vaccinations. All necessary vaccines due will be administered today. You should have been advised on whether or not a fast was required, and if so, for how long. The admission process involves signing this "permission to treat" form. Your business' contact telephone phone number, and if this pet is owned, the owners contact telephone phone number is required upon admission. After admission, the animal will be examined and weighed. If our doctors have any questions, they will contact you, or the business responsible at the phone number left above. Once all services are complete, you or the business responsible will be contacted at the telephone numbers supplied on this form.

In some cases, anesthesia or sedation may be required in order to successfully complete certain procedures. If this is necessary, you or the business responsible will be contacted by a doctor. All patients undergoing general anesthesia will undergo routine pre-anesthetic testing to ensure safety. All pets will also receive intravenous fluids during their procedure. The type of anesthesia used is dictated by the age and health as well as the procedure being performed. Only the safest anesthetic protocols are used and patients are closely monitored by a nurse anesthetist as well as with monitoring devices such as pulse oximetry, electrocardiogram, blood pressure, respiratory, and temperature monitors. During the recovery period, or shortly thereafter, the nurse or doctor will call to let you know how everything went. Although every effort is made to ensure a safe and painless procedure, there are always some risks associated with any form of anesthesia (if needed). These risks may include decreased blood pressure, cardiac arrhythmias, apnea, body temperature variations (hyperthermia, hypothermia), idiosyncratic reactions to a particular drug, prolonged recovery times, and death. Additionally, there may be complications related to the procedure itself. Complications can occur during and after a procedure is completed. In addition to discussing potential risks associated with the procedure, the doctor or nurse should have answered any unresolved questions or concerns that you may have.

I understand and agree to everything stated in this document. Planned treatments for this pet have been explained to my satisfaction. I authorize South Wilton Veterinary Group to perform the scheduled service(s) and/or procedure(s) on this pet.

Date Signed

Date

Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach you, the practice is authorized to perform the treatment selected below:

CPR (Cardiopulmonary Recessitation)DNR (Do Not Resuscitate)

Signature

In the event life saving measures are performed, you assume all financial responsibility for such care. You also understand that life-saving measures are not a guaranteed success 100% of the time.

Date Signed

Date