Patient Drop Off Sheet
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  • Patient Drop Off Sheet

  • Thank you for choosing Pioneer Veterinary Clinic! 

     

    The following information will be used to help our veterinary team treat your pet. Please read, fill-in, and sign, for a fast check in process.

  • We will need to be able to contact you or someone with permission to make medical and financial decisions. 

  • Date
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is the reason for today's visit?*
  • Are there any concerns for:(check all that apply) Our Veterinarian will address these concerns and contact you about a treatment plan.
  • Has your pet ever had an adverse reaction to any medications?*
  • Has your pet ever had an adverse reaction to vaccines or any procedure?*
  • Is your pet ever in pain after vaccines or other procedures*
  • Is your pet taking any medication(s)?
  • Time of next dose
  • Any refills needed?
  • Pre-anesthetic Bloodwork: We take every step possible to minimize anestehetic risk for our patients. We recommend a blood profile for all age patients. This test checks the overall health, organ health and blood counts that will be used as a reference point in the future. This test is REQUIRED for all patients over 3 years of age. If your pet is 3 and under, do you wish to have this service? Today, this service is $105. Normal price is $165.*

  • Once the pre-anesthetic blood work results are in, we will notify you if an abnormalities are detected. Based on the veterinarians discression, the procedure may proceed, be rescheduled, or canceled. Please monitor you phone while your pet is staying with PVC.

  • Heatworm Prevention: Heartworm disease is preventable with annual, bi-annual and monthly options available for your pet. The cost of the test today is $46. This test checks for heartworms and multiple tick diseases. Would you like to run this test today?*
  • Are you interested in heartworm prevention today? Price will depend on weight and duration of medication*
  • Fleas and Tick Prevention: Fleas and ticks carry many diseases and cause discomfort to pets and people. If LIVE fleas or ticks are found on your pet a control product will be administered. A CHARGE will appear on your statement. Would you like to discuss flea and tick prevention today?*
  • Microchips: 10 million pets are lost each year and 80% are never found. A Microchip is a small price to know your loved one is protected. This product is $25. Would you like to get your pet microchipped today?*
  • IV Catheter & Fluids: An IV catheter can be a life saving tool should your pet need emergency treatment during a procedure. This allows the team to administer fluids and fast acting medications. An IV catheter can help patients recover from procedures. This service is $65. Would you like your pet to have an IV catheter to helps their recovery today?*
  • Anal Gland Expression: These glands are found along the edge of the ans and contain a foul smelling liquid. They normally empty when the pet has a bowl movement. If your pet is licking, chewing, or scooting their backside, these glands maybe blocked. There is a $20 charge for this service. Would you like the team to preform this service for your pet today?*
  • Skin and Dental Products: PVC carries and effective skin care and dental products so you can address your pet's needs. Which items would you like to discuss today?

  • Additional Surgical Services PVC Requirments:

  • Post-Procedure Medication: 

     

    All surgical patients are required to leave with pain medications. Charges will be applied.If disease is found, antibotics or other medications based on the diagnostics may be prescibed. Additional charges may apply.

     

     Patients must be current on ALL vaccinations to be treated and housed at Pioneer Vet Clinic.  IF your pet is NOT vacinated by a licensed veterinarian, the pet will be vaccinated at your expense. Un-vaccinated pets risk the potetial of spreading or contracting contagious illnesses. A full set of vaccinations is $75.

     

    I assume FULL financial responsibility and understand the potiential risks associated with anesthesia and surgery. I have read and agree to all statements and information provided on this form.

  • Date*
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  • Should be Empty: