Outpatient Form(Drop-Off Appts)
Please answer the following questions so that we can better serve you and treat your pet.
In order to reduce the risk of exposure to COVID-19 for the staff and the other clients, we are asking that clients who are ill reschedule their appointment, or have another person bring in their pet. In the event that the visit is an emergency, and no other person is able to bring in pet, we are asking that the client inform our staff (over the phone) of the illness before interacting with them, so they can utilize additional safety protocols. ***I confirm that I have not traveled from a high risk area in the last 2 weeks, and that I am not experiencing any illness that could be related to a COVID-19 infection.
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Owner's Name
First Name
Last Name
Email
example@example.com
Pet's Name
Today's Phone Number
-
Area Code
Phone Number
Has your address or phone number changed since your last visit?
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No, everything is the same.
Yes, my phone number has changed.
Yes, my address has changed.
Yes, both have changed.
Other
If any of your information has changed since your last visit, please enter the new information below.
Do you have a doctor preference? Please understand that while we will attempt to accommodate your request, not all doctors work every day, and your preferred doctor may not have an opening today.
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Yes
No
If yes above, my preferred doctor to see my pet is
Please Select
Dr. Kevin Brumfield
Dr. Sondra Brown
Dr. Kathleen Cavell
Dr. Jennifer Smith
Dr. Alicia Smith
Dr. Jennifer Fleck
Dr. Alex Baumgartner
Dr. Sarah Petrario
Our doctor will perform a comprehensive examination of your pet today. Once that is performed, they may recommend procedures or testing to further help your pet with any conditions they find. Please select one of the below options.
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Please perform all recommended testing or treatments for my pet today, as the doctor deems necessary. I can be informed of the testing and treatments and their associated costs once my pet is finished for the day.
Please CALL me once the examination is complete. I would like to be informed what testing or treatments and their associated costs are recommended for my pet before they are completed.
Please TEXT me once the examination is complete. I would like to be informed what testing or treatments and their associated costs are recommended for my pet before they are completed.
Please give a brief description of the reason for visit.
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Please list any additional procedures you would like performed while your pet is here today (nail trim, anal gland expression, etc). Please understand there may be additional costs associated with any procedures performed.
I understand that my pet will be utilizing supplies and staff attention today, and that because of that I will be charged $4.50 for the boarding over the course of the day.
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By signing below with my finger or mouse, I attest that I understand that payment for all services is due at the time of pick-up.
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