Patient Drop Off Sheet

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

MonthDayYear
Date
Name(whom we will be speaking with about the pet)*

First NameLast Name
Pet name*
1st phone*
Cell Phone
2nd phone*
Work Number
Primary Email*
example@example.com
What is the reason for today's visit?*

Flex AppointmentEmergencyWeight ManagementComprehensive ExamGeneral Surgical AppointmentSpay or NeuterVaccinesRecheckDental ProcedureFlu
Other
Are there any concerns for:(check all that apply) Our Veterinarian will address these concerns and contact you about a treatment plan.

EatingWeight GainCar SicknessBehavioral ProblemDrinkingItching/ScratchingVomitingBad BreathDifficulty RisingDiarrheaExcessive SleepingScootingSkin Masses/LesionsWeight LossShaking HeadUrination IssuesOther
When did your pet last eat?*
Has your pet ever had an adverse reaction to any medications?*

YesNo
If so, describe
Has your pet ever had an adverse reaction to vaccines or any procedure?*

YesNo
If so, describe
Is your pet ever in pain after vaccines or other procedures*

YesNo
If so, describe
Is your pet taking any medication(s)?

YesNo
If so, list
Time of next dose

ampm
Any refills needed?

YesNo
Please call me before treating if my fee will be over $ (if left blank, we will call if fee is over $100)*
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.*

YesNo
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?*

YesNo
Are you interested in heartworm prevention today? Price will depend on weight and duration of medication*

YesNo
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?*

YesNo
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?*

YesNo
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?*

YesNo
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?*

YesNo
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?

ShampooWipesEar CleanerDental Care
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.
Owner/Agent of Owner Signature*

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First NameLast Name
Date*

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Date
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Patient Drop Off Sheet

Additional Surgical Services PVC Requirments: