Drop Off Form

Drop off Intake

Convenient Drop off Appointment Release
Full Name*

First NameLast Name
Pets Name *

Name
Phone Number*
Secondary Phone Number
Email*
example@example.com
Please ensure that you are available by phone at ALL times until your pet is released back into your care.
Please enter Diet and Feeding information.*
Check the conditions that apply to your pet.*

CoughingSneezingVomitingDiarrheaEye DischargeDirty/Itchy EarsNasal DischargeLimpingSkin IssueNew or changed lumpNo concernsOther
How long has this condition been going on for and with what frequency?
Has your pet experienced this condition in the past?
Check the symptoms that your pet is currently experiencing:*

Not eatingTrouble breathingTrouble DefecatingTrouble UrinatingWeight gainWeight lossChange in behaviorChange in activity levelNo concernsOther
How long has this symptom been going on for and with what frequency?
Has your pet experienced this symptom in the past?
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.
Has your pet ever had a reaction to vaccinations?*

YesNoNot Sure
Please indicate what preventatives or medications you need a refill of:

BravectoInterceptorSimparica TrioRevolutionOther
Which preventative care procedures are you approving? (Select all that apply)*

Rabies VaccineDistemper VaccineBordetella VaccineInfluenza VaccineLyme VaccineLeptospirosis VaccineFeline Leukemia VaccineIntestinal Parasite (Fecal) Lab testHeartworm/Tick Parasitology (Blood) testAnnual Full Organ Function Lab ScreeningUrinalysisOther
Are there any other issues/concerns that you would like to discuss at your appointment?
I authorize VMVH the budget below to do what is necessary for my pet's care today. Anything beyond this amount will require a verbal authorization before continuing.
A topical treatment will be applied at the my expense to any pet with evidence of fleas, flea dirt, or ticks. I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital.
Please type in your initials
Authorization: I authorize VetMED Veterinary Hospital to do whatever is necessary should an emergency arise. Should be my pet become ill or inure itself, and VMVH is unable to contact me at the numbers that I have provided, my pet will be treated as deemed necessary by the attending dvm at my own expense.
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Please arrive to your appointment at your scheduled time. Due to our current scheduling restrictions, if you are not able to arrive on time, we may need to reschedule your appointment.
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Drop off Intake