Patient Drop Off Form

We are happy to host your pet today - thank you for entrusting them to our care.

Please, help us prepare for their stay by completing the following information at least the day before drop-off.

Drop off time: Between 7:30am and 9:00am (on the early side of this window is preferred).

Pick-up time: Between 4:00pm and 4:45pm.
Pet Name*
Client Name*
Date of Drop off*

MonthDayYear
Date
Contact Preference (checkbox then add contact info):

Phone callE-mailText message
Phone call:
E-mail:
Text message:
Preferred pick-up time request: (we will do our best to accommodate requests, but our standard pick-up time is between 4:00pm and 4:45pm)
If necessary, I give permission for anesthesia/sedation procedures to be performed, under medical needs.*

YesNo
ANTI-NAUSEA SUPPORT [$55 for pets up to 65lb, $70 for dogs over 65lb] - Nausea can be one of the most unpleasant parts of anesthesia for pets and people. This treatment will help your pet feel better, guard against vomiting while your pet is under anesthesia, and get them back to eating and acting normally as quickly as possible. We feel strongly that this treatment is a great benefit to many patients, and the cost is the only reason it is not automatically included with our sedated procedures.*

YesNo
Last meal:
Current medications:
Current heartworm prevention:*
What was the date of your pets last dose of heartworm prevention*

MonthDayYear
Date
Current fleatick prevention*
What was the date of your pets last dose of flea/tick prevention*

MonthDayYear
Date
Type of visit:

Sick visitAnnual visitTechnician visit
(For "Sick visit" only): Please, list history and information that will help your veterinarian:
Can we start with necessary diagnostic tests before we contact you?

YesNo
(For “Annual visit” only): Annual examination, vaccination and testing (please, check all that apply):

DHPP (Distemper/Parvo)RabiesLeptospirosisBordetellaFVRCP (Feline)Feline LeukemiaFeline Rabies 1yr PurevaxFeline Rabies 3yr PurevaxAnnual heartworm/tick testingLyme vaccinationCanine flu vaccinationAnnual fecal intestinal parasite testingWellness labwork
Any additional requests?
(For “Technician visit” only): Please, select all that apply:

Nail trimAnal sac expressionBathUrine sample collectionVaccinationsLabworkOther
(For "Vaccinations" only): Please, specify:
(For "Labwork" only): What type:
Anything else you need to let us know?
I give the veterinarians of Central Providence Veterinary Hospital consent to diagnose and treat my pet's condition and I state that we will be fully responsible for all fees and charges and will pay for all charges incurred on my pet's behalf upon the day of service. (Must be at least 18 years old):

Clear
Printed name (Must be at least 18 years old):
Should be Empty: