Drop off form - River Park Animal Clinic

The information requested will inform us of specific services you want us to provide for your pet. This way we can be certain that we understand what your pet needs, and will best satisfy your expectations. If you are unable to show proof of rabies, we will vaccinate your pet for the safety of our staff as well as your animal. If we need additional information, we MUST be able to reach you at the number you give us today.

I am the owner or the authorized agent for the owner of the animal described on this letter, and I have the authority to execute this consent.
Client's Name
Phone number
Pet's Name
Are there any other issues/concerns you have about your pet? Please provide a brief summary of any problems/issues
When did you first notice these symptoms?
Have you given your pet anything for this problem? What was the response?
Current diet - Name of brand and amount
Did your pet eat this morning?
Any allergies?
Is your pet on any medications? Please list them here and how you are giving them. This is to make sure there have been no changes from the prescribed label.
Are you currently using heartworm prevention? Please list product you are using and date last given. *Remember heartworm disease is a year-round disease and medication should be given year-round. It only takes one bite by a mosquito to pass heartworm and heartworm disease can be deadly. This is a good time to check to see if you may have missed doses. If you have, it may be time to discuss Proheart, an 12 month injection for heartworm. We can provide you with an estimate of cost at time of visit
Are you currently using flea tick prevention? Please list product you are using and date last given. *Remember that fleas are out year-round. This is a good time to take stock of your flea/tick prevention. We recommend Simparica, an oral chewable tablet given monthly to best protect your pet from fleas and ticks.
If your cat

Inside onlyOutside onlyBoth

If deemed medically necessary by the veterinarian, I authorized the following:

	Yes	No
Flea treatment if your pet has fleas
Sedation (cost varies due to weight)

Please Note: If your pet cannot be handled without sedation, we will be unable to complete the physical exam without authorization to sedate. Sedation is used only when necessary for the safety and well-being of your pet and the staff.
I authorize any diagnostic testing (bloodwork, urinalysis, radiology, cytology,etc) up to $ blanks. Call before exceeding the above amount
Have you notice your pet having any of the problems below? Please check all that applies

Straining to UrinateIncrease in UrinationDiarrheaConstipationPain (please elaborate specific leg)Decreased appetiteLumps or bumps please draw on the picture belowWatery eyesLimping (please elaborate specific leg)Change in behavior (please elaborate)LethargyIncreased thirst/water intakeGaggingSneezingItchingHair lossWeight lossWeight gainCoughingPantingScootingVomitingShaking headNasal discharge
Please elaborate on the choices selected
Would you like any other services done today? Please circle all that are wanted.
Canine Vaccine

RabiesLeptoDistemper ParvoInfluenza
Feline Vaccine

RabiesFeline distemperFeline leukemia
Other services

Nail TrimExpress anal glandEar cleaningFecal testHeartworm testWellness bloodworkClipping matt
I understand that some risk always exists with sedation, even in apparently healthy animals, including the possibility of death. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics, as deemed necessary by the veterinarian. I have carefully read, and fully understand, this consent.

If you have not heard from us, please call us around 4 pm to check on the status of your pet's exam. Drop-off exams are worked in during the day, between scheduled appointments or when the veterinarian is available. If we have a question regarding your pet's treatment or need authorization to perform a test, and cannot reach you, we will wait until you call us to finish your pet's exam and treatment. In cases of examinations where there is an immediate threat to the well-being of your pet and we are unable to contact you, our veterinarians will take the necessary steps to stabilize your pet and/or alleviate pain until we are able to contact you. Please note that payments are due at the time of service. By signing below, you agree to the above terms and
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