Drop Off Questionnare
Date:
Have we seen you or your pet before?
Yes
No
Please click
this link
to be directed to our registration form.
Is this your pet?
Yes
No
Owner's Name
*
First Name
Last Name
Contact Name
*
First Name
Last Name
How would you like us to contact you today? (Please choose one)
Phone call
Text message
Email
Contact Phone Number Today
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Species (pick one)
Canine (dog)
Feline (cat)
Exotic
Other
Pet's Name:
Pet's Description
Breed/Color/Markings
Pet's Age
Approximate or DOB
What is the primary problem/reason for visit today?
What are the symptoms?
When did you first notice the problem?
Is your pet still eating?
Yes
No
Some, but not as much as normal
Is your pet still drinking?
Yes
No
Some, but not as much as normal
How is your pet feeling?
Normal
Lethargic/Depressed
Is your pet vomiting or having diarrhea? (Select all that apply)
Vomiting
Diarrhea
Neither
Is this the first time your pet has had this problem?
Yes
No
Please list dates of other occurrences
How long did it last?
Was the problem treated by a veterinarian or did it go away on its own?
Treated by a veterinarian
Went away on its own
Is the problem getting better, worse, or staying the same?
Better
Worse
Remain the same
Please provide further information, if applicable
Has your pet ever had a similar problem?
Yes
No
How long ago?
Is your pet on any medications? (Including heartworm and flea preventatives)
Yes
No
Please list the medications, if known
Do you know if your pet is allergic to any medications?
Yes
No
Please list the medications
Are there any other problems we should be aware of today?
Yes
No
Please list the problems/additional concerns
I authorize the veterinarian to sedate my pet if deemed necessary
*
Yes
No
Please choose one:
*
I authorize the veterinarian to examine my pet. PLEASE CALL BEFORE any diagnostic testing and treatment.
I authorize diagnostic tests and/or treatment NOT TO EXCEED $350.00 as recommended by the veterinarian without telephoning me, including laboratory tests and radiographs.
I authorize ANY diagnostic tests and/ortreatment recommended by the veterinarian without telephoning me, includinglaboratory tests and radiographs.
I HEREBY ACKNOWLEDGE THAT THE EL DORADO ANIMALCLINIC DOES NOT BILL FEES. PAYMENT IS EXPECTED AT THETIME SERVICES ARE RENDERED. ANY UNPAID ACCOUNTS ARE SUBJECT TO A 2%FINANCE CHARGE AND $10.00 BILLING CHARGE PER MONTH.
*
I have read this statement and understand
I need additional information
Signature
*
Submit
Should be Empty: