Veterinary Drop Off Consultation Consent Form

Drop Off Visit Consent Form

Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Pet's Name*

First NameLast Name
Who is your pet seeing today?
Your Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
It is imperitive that we be able to reach you in a timely manner while your pet is in the hospital today. Please have your mobile phone listed above available and be free to talk.
Where can we call you at while your pet is here?*

Area CodePhone Number
Is there anyone else we can call regarding your pet while they are here today?

YesNo
Alternative Contact Name*

First NameLast Name
Alternative Contact Phone*

Area CodePhone Number
Reason for your pet's visit today?
If surgical, please list surgery type (i.e. Spay, Neuter, Dental Cleaning, Mass Removal etc.)
Has your pet had any food since midnight last night?

YesNoUnsure
Has your pet been vomiting or having diarrhoea?

YesNoUnsure
Does your pet have any allergies?

YesNoUnsure
If yes, please describe/provide more information
Has your pet ever had any adverse reaction to medication?

YesNoUnsure
If yes, please describe/provide more information
Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given:
When Was Your Pet's Last Dose of Flea/Tick Preventative?
Date Given (Please type N/A if not on a preventative)
What Kind of Flea/Tick Preventative Do You Use?
Name of medication - put unknown if not sure
Please note: Bendigo Pet Vets will require that a treatment will be applied at the owner’s expense to any pet with evidence of fleas, flea dirt, or ticks.
Initial Above
Is Your Pet Current On Vaccinations?

YesNoI Am Not Sure
My pet's vaccines were administered last by:

At Bendigo Pet VetsI Am Not Sure WhereOther
Does Your Pet Have A Microchip?

YesNoI Am Not Sure
Do you want your pet microchipped today? (Additional Fees Apply)

YesNo
Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?
If yes, please tell us more. If no, please note N/A
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
Are there pictures or video that would help us with our exam today?

Please upload if available.
Cancelof
Is There Anything Else You Would Like To Discuss Today?
Authorizations
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Bendigo Pet Vets. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.*
Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is discharged from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).*
Initial
Signature*

Powered by Jotform SignClear
Should be Empty:

Drop Off Visit Consent Form

Authorizations