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

Date

Contact Preference (checkbox then add contact info):

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.

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.

Last meal:

Current medications:

Current heartworm prevention:

What was the date of your pets last dose of heartworm prevention

Date

Current fleatick prevention

What was the date of your pets last dose of flea/tick prevention

Date

Type of 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?

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

Any additional requests?

(For “Technician visit” only): Please, select all that apply:

(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):

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