HVH Drop-Off Consent Form 2023

Drop Off Consent Form, Fillable
Hillside Veterinary Hospital

191 Augustine Avenue Suite 100, Charles Town, WV 25414 // (304) 728-2203

www.hillsideveterinaryhosptial.com
Drop Off Consent Form

Drop Off's will be scheduled with an "arrival time", this is not an appointment, and your pet will be admitted to the hospital for the day. Our doctors look at drop offs in between scheduled appointments, with emergencies taking precedence. Our staff will be in touch once your pet has been examined. Please plan accordingly. In order for us to best understand why your pet is being dropped off, please fill out this form in its entirety, prior to your pet's visit. *Please note - we cannot guarantee which doctor will be seeing your pet while here, as we examine pets in the order in which they are dropped off*
Client Information
Client Name*

First NameLast Name
Date of Drop Off*
Enter a date; (ex. 06/12)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Phone Number
Email
example@example.com
Pet Information
Pet Name:*
Pet Sex:
Pet Birth Date:
Birth date or approximate age
Feline/ Canine:
Pet Breed:
Pet Color:
For Cats Only:

IndoorOutdoorIndoor/Outdoor
Is your pet on HEARTWORM medication?

Yes (please provide what brand in the box below)No
Type of HEARTWORM medication
Is your pet on FLEA/TICK medication?

Yes (please provide what brand in the box below)No
Type of FLEA/TICK medication
Is your pet on any other medications? If so, please list.
Last dose of medication?
What is the main reason for your pet's visit today? Please provide as much detail as possible.*
How long has this been going on?
Has this problem gotten better/worse/same?

BetterWorseSame/unchanged
Have you provided any treatment(s) at home? If so, please list.
Please check any symptoms your pet is experiencing:

VomitingDiarrheaConstipationLethargy/WeaknessBlood in StoolCoughingSneezingShaking HeadLack of AppetiteIncreased drinking/urinationScratching -- Indicate Location(s) BelowLump(s) -- Indicate Location(s) BelowLimping -- Indicate which leg(s) Below
If scratching, where?
If limping, which leg(s)?
If lump(s), indicate location(s):
To assist your pet as quickly as possible, do you give permission to do the following (if deemed necessary by the Veterinarian?

Lab WorkX-RaysSedation/Anesthesia
Please indicate which vaccinations, tests, and/or services you would like us to perform today:

Note: WV state law requires a current Rabies vaccination on all pets. If your pet is not current, we are legally obligated to vaccinate for Rabies while here today.
DOGS

DOG: Rabies VaccineDOG: DHPP VaccineDOG: Lyme VaccineDOG: Bordetella VaccineDOG: Canine Influenza VaccineDOG: Leptospirosis VaccineDOG: Heartworm/Lyme/Ehr/Ana Snap Test
CATS

CAT: Rabies VaccineCAT: 4in1/FVRCP VaccineCAT: Leukemia VaccineCAT: Leukemia/FIV/HW Test
ADDITIONAL SERVICES

Additional Service: Anal Sac ExpressionAdditional Service: Nail TrimAdditional Service: Microchip
AUTHORIZATION: I verify I am the owner (or Authorized Agent) of the above-named pet and authorize the above procedure(s) to be performed. I agree to be responsible for any charges incurred while my pet is in the care of Hillside Veterinary Hospital and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet if it stays overnight (pets needing special care may be referred to a 24-hour hospital).
Best Phone Number to reach you at TODAY:*

Area CodePhone Number
May we text this phone number?*

YesNo
Owner/Agent Name (print)*
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Drop Off Consent Form, Fillable

Drop Off Consent Form

Client Information

Pet Information