Urgent Care Drop Off
Name
First Name
Last Name
Pets name
Name
Breed
Sex
Age
Does your pet have any previous medical conditions?
Has your pet had any allergic reactions to drugs or vaccines in the past?
Is your pet on any current medications? Please list name, dose, and last time medication was given
Is your pet on any preventative medications - flea/tick and heartworm?
Does your pet have any history of aggression or fear based incidents?
Please describe the reason for bringing your pet in today:
Is your pet eating and/or drinking more or less than normal?
Is your pet urinating more or less than normal?
Is your pets energy level normal?
Has your pet had any coughing or sneezing? How often?
Has your pet had any vomiting or diarrhea? How often?
Yes, please perform necessary diagnostics to expedite my visit and further investigate underlying causes. Estimated cost of $300-$700 (may include but not be limited to bloodwork and radiographs)
Please do not perform any diagnostics without further discussion and a formal treatment plan outlining associated cost.
CPR: I request that, in the event of an emergency where my pet begins to experience cardiac and/or pulmonary arrest, that the doctors and staff immediately begin to perform resuscitation (CPR) efforts. I acknowledge that I will be responsible for any additional fees for these resuscitative attempts, which are incurred above any estimates given.
DNR: I request that, in the event of an emergency where my pet begins to experience cardiac and/or pulmonary arrest, that the doctors do not attempt any resuscitation (CPR) efforts.
By signing below, I authorize the medical care team to administer pain medications and/or medications to make my pet relaxed during their vet visit. Please note that if you do not select this option, then we are unable to offer a drop off visit and you may be requested to wait with your pet until the veterinarian is available.
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