SWV Patient Drop-Off Authorization for Treatment

Patient Drop-Off Authorization for Treatment
Name*

First NameLast Name
Pet's Name*
Best Phone Number Day of Exam/Treatment*
Please enter a valid phone number.
Have you moved? If yes, please update your address here:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address:
example@example.com
Reason for Exam/Treatment:*
If necessary for examination, do we have permission to sedate or anesthetize your pet:*

AcceptDecline
When did you first notice the problem?
What has your pet been treated with at home?
How has your pet's appetite and water consumption been?

Less than normalNormalMore than normalNot eating/drinking
What has your pet eaten today and when?
Is your pet on any medication? If yes, please describe:
Are there any problems your pet might have of which we should be aware?
To effectively diagnose and treat many problems, x-rays, blood tests, and other procedures may need to be done. We will notify you before undertaking these tasks as to their need and cost. In the event of a life-threatening condition, we will make every attempt to stabilize your pet and notify you as to the extent of the problem as soon as possible.
Flea / Tick Policy:

If your pet has fleas or ticks, he or she will be treated at your expense in order to maintain an optimal environment for all patients.

Patients who are on a flea preventative but still have fleas will be administered a dose of Capstar at your expense. Capstar kills adult fleas before they can lay eggs and cause an infestation. The medication begins working within 30 minutes of application and kills over 90% of adult fleas within a few hours. The expense to administer Capatar is $20.
Is your pet current on flea control?*
If "other" please specify:
Date last given:

MonthDayYear
Date
Authorization

I hereby authorize Stiern/Southwest Veterinary Hospital to give standard and accepted treatment necessary for the well being of my pet, and agree to be responsible for any and all costs incurrec in connection with treatment. I understand only minimum diagnostics and/or treatment will be administered to my pet until which time that I can be contacted for authorization.
Signature:*

Clear
Today's Date:*

MonthDayYear
Date
Should be Empty: