Out-Patient (Drop-off Appointment) Form
Please answer the following questions so that we can better serve you and treat your pet.
Owner's Name
*
First Name
Last Name
Pet's Name
*
Date
-
Month
-
Day
Year
Date
Today's Phone Number
*
Format: (000) 000-0000.
Has your address or phone number changed since your last visit?
*
No, everything is the same.
Yes, my phone number has changed.
Yes, my address has changed.
Yes, both have changed.
Other
If any of your information has changed since your last visit, please enter the new information below.
3. Our doctor will perform a comprehensive examination of your pet today. Once that is performed, they may recommend procedures or testing to further help your pet with any conditions they find. Please select one of the below options.
*
Please perform all recommended testing or treatments for my pet today, as the doctor deems necessary. I can be informed of the testing and treatments and their associated costs once my pet is finished for the day.
Please CALL me once the examination is complete. I would like to be informed what testing or treatments and their associated costs are recommended for my pet before they are completed.
Please TEXT me once the examination is complete. I would like to be informed what testing or treatments and their associated costs are recommended for my pet before they are completed.
9. Please give a brief description of the reason for visit.
*
CPR
I wish the staff of Vetfield Animal Hospital to perform CPR (Resuscitation) on my pet if my pet suffers respiratory or cardiac arrest. I understand that my pet may not respond to CPR or may respond initially and then suffer another arrest afterward.
I DO NOT want CPR performed on my pet in the event my pet stop breathing and/or his or her heart stops beating. I elect to have a DNR (Do Not Resuscitate) order placed on my pet’s record OR I elect that the veterinary staff stop the initial attempts at CPR that may have been started while I was being informed of the condition of my pet and my options.
I hereby authorize the veterinarian and Vetfield Animal Hospital & Mobile Vet to examine, prescribe for, or treat the above-described pet. I will assume responsibility for all charges incurred for the care of this animal. I also understand that these charges will be paid at completion of service or time of release and that a deposit is required for surgical and/orin-hospital treatments.Vetfield Animal Hospital & Mobile Vet does have permission to give my pet a sedative or anesthesia if necessary.Vetfield Animal Hospital & Mobile Vet does have permission to run blood work if necessary.
Signature
I acknowledge Vetfield animal Hospital is not a 24 hour emergency hospital and my pet will be without personal supervision overnight
Yes
No
Other
Signature
10. Please list any additional procedures you would like performed while your pet is here today (nail trim, anal gland expression, etc). Please understand there may be additional costs associated with any procedures performed.
By signing below with my finger or mouse, I attest that I understand that payment for all services is due at the time of pick-up.
*
Continue
Continue
Should be Empty: