Drop Off Consent Form

Patient Drop Off Consent Form
Client Name*

First NameLast Name
Pet's name being dropped off. *
Best contact number to reach you during your pet's visit. *
Please enter a valid phone number.
Reason for today's visit.*

VaccinesNail TrimAnal gland expressionExam (please describe issues below)Other
Please describe in detail any issues your pet is experiencing. *
Have you noticed any vomiting or diarrhea?*
Have you noticed any sneezing or coughing?*
Have you noticed any new lumps or bumps? *
Is your pet currently on any medications and/or heartworm, flea, or tick prevention? Please include: name of medication, dose given, and last time the medication was administered. *
Please let us know if you need any refills while your pet is with us today.
Do you need any refills on medications while your pet is with us?*

Does you pet have any known allergies or vaccine reactions? If yes, please list them below. *
What brand of food is your pet eating? How much and how often are you feeding?*
Has there been a change in their appetite or thirst?*
When did you pet last eat or drink? *
How is their mobility? Any issues getting around?*
What is their environment? Indoor/outdoor/both? List any other pets in the household if any. *
Has your pet traveled recently with you? If so, where? *
If needed, I authorize diagnostics/treatment up to the amount of $ blank to start. I am aware that the price is subject to change depending on my pet's diagnosis and/or treatment plan moving forward.
Please call me before preforming any diagnostics or treatment.*

YesNo, move forward with what the doctor deems necessary.
I authorize FurWell Veterinary Hospital permission to examine, prescribe for, and/or treat my pets. I accept responsibility for all charges associated with the care of all the pets on my record. I am aware that these charges must be settled at the time of the pets' release, and I acknowledge that a deposit may be necessary prior to my pet's visit (if a deposit is required the staff will notify you ahead of time). Additionally, I understand and agree that all charges are due in full upon the discharge of my pet.
Signature*

Clear
Date*

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Patient Drop Off Consent Form