Patient Drop Off Consent Form

Patient Drop Off Consent Form
Client Name*

First NameLast Name
Name of Pet being dropped off*
Best contact number to reach you during your pet's visit.*
Please enter a valid phone number.
Reason for today's visit:*

VaccinesNail TrimAnal Gland ExpressionExam (please describe issues below)Other
Describe in detail any issues your pet is experiencing:*
Have you noticed any vomiting or diarrhea?*
Have you noticed any sneezing or coughing?*
Is your pet currently on any medications and/or heartworm, flea, or tick prevention? Please include: name of medication, dose given, and last time the medication was administered.*
Do you need any refills on medications while your pet is with us today?*

Does your pet have any known allergies or vaccine reactions? If yes, please list them below.*
What brand of food is your pet eating? How much and how often are you feeding?*
Has there been a change in their appetite or thirst?*
When did your pet last eat or drink?*
How is their mobility? Any issue getting around?*
What is their environment? Indoor/outdoor/both? List any other pets in the household if any.*
Has your pet traveled with you recently? If so, where?*
If needed, I authorize diagnostics/treatment up to the amount of $ blanks* to start. I am aware that the price is subject to change depending on my pet's diagnosis and/or treatment plan moving forward.
Please call me before performing any diagnostics or treatment.*

YesNo, move forward with what the doctor deems necessary.
I authorize FurWell at Barkingham permission to examine, prescribe for, and/or treat my pets. I accept responsibility for all charges associated with the care of all the pets on my record. I am aware that these charges must be settled at the time of the pets' release, and I acknowledge that a deposit may be necessary prior to my pet's visit (if a deposit is required the staff will notify you ahead of time). Additionally, I understand and agree that all charges are due in full upon the discharge of my pet.
Signature*

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