Canine Drop Off Exam & Release Form
This form should only be completed if you have scheduled a drop off exam. If you are unsure if your appointment is a drop off exam, please email us at customer.care@ahdcvets.com.
Owner and Pet Information
Owner's Name:
*
First Name
Last Name
Owner's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Email:
*
example@example.com
Pet's Name:
*
Canine Exam Questions
How has your pet been since your last visit? Have you noticed any of the following problems?
*
Change in urination, drinking, or defecation
Change in appetite or vomiting
New or growing lumps
Limping, slowing down, decreased or hesitant jumping
Behavioral issues (ex: aggression, phobias, destructive behaviors, etc.)
None
Do you have any other concerns?
*
If none, please type "N/A".
Please list everything your pet eats throughout the day. Start in the morning through the end of the day, including extra foods outside of kibble. Please also list Brands and amounts of food and treats.
*
Describe your pet's normal daily activity.
*
Does your pet go to the following:
*
Boarding
Grooming
Dog Parks
Obedience/Training Classes
Come in contact with other neighbor pets
Hunting/Hiking
Come in contact with farm animals
None
Other
If other, please list.
What type of Heartworm Prevention do you use?
*
If none, please type "None".
When was the last dose given?
/
Month
/
Day
Year
Date
What type of Flea/Tick Prevention do you use?
*
If none, please type "None".
When was the last dose given?
/
Month
/
Day
Year
Date
How many months throughout the year are you giving the preventions?
*
Year-round
Seasonal
None
Have you seen any fleas or ticks on your pet?
*
Yes
No
Is your pet on any other medications? If yes, please list the medication, dose, and frequency.
*
If none, please type "None".
Have you missed any doses?
Yes
No
What type of dental care do you provide your pet?
*
Brushing
Treats
Water Additives
None
Hospitalization Release
I authorize this hospital to perform an exam and approved diagnostics on my pet.
*
Initial Here
I authorize the use of appropriate anesthesia and other medications as needed. I understand that during the performance of the above listed treatment/procedure(s), unforeseen conditions may be revealed that necessitate an extension of the procedure(s), or different procedure(s), than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian's professional judgement and the animal's best interest. I understand that I can terminate treatment at any time by contacting the attending veterinarian. I also understand the staff of AHDC will follow all responsible precautions against illness, injury, or escape of my pet(s), but they will not be help liable or responsible in any manner whatsoever, under any circumstances, on account of the care, treatment, or safe keeping of my pet(s), as it is thoroughly understood that I assume all risks.
*
Initial Here
I understand that certain treatments and procedures pose some risks to the patient that the precautions will be taken to minimize such risks. Unfortunately, in some cases, you pet's condition may decline to a point where a decision must be made whether or not to perform cardiopulmonary resuscitation (CPR). I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed and that my financial obligation remains regardless of the outcome.
*
Initial Here
All animals entering the hospital, unless medical conditions prevent, must be current on vaccinations and free of external parasites or they will be treated at the owner's expense. I agree to pick up my pet within five (5) days of the discharge date, and my pet may be considered abandoned if I do not pick up my pet within those five (5) days. In my failure to recover my pet, the hospital is authorized to take the appropriate action as deemed professionally necessary.
*
Initial Here
I understand that AHDC is not a 24 hour care facility. The hospital is not staffed with medical personnel between hours of 9:00pm-7:00am. If my pet is determined to be in critical condition, I will be provided with options that will ensure proper care is provided to my pet during these times.
*
Initial Here
The doctors and staff will do their best to keep me updated on my costs should they extend beyond the scope of the estimate, but it is my responsibility to request updates should the treatment plan change. Full payment is due upon release of the pet. Pets are released only during regular office hours.
*
Initial Here
Telephone number where the owner can be reached during the time of procedure:
*
-
Area Code
Phone Number
Is your pet on any medications, including aspirin? If yes, please list the medication(s) and dosing.
*
If none, please type "N/A".
Has your pet been drinking and eating normally lately?
*
Yes
No
Has your pet had any recent weight changes?
*
Yes
No
Would you like CPR to be performed on your pet?
*
Yes
No
I have read and understand this authorization and consent.
*
Date:
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: