Drop-Off Form

Drop-Off Form
Client Name*

First NameLast Name
Client's Email*
example@example.com
Pet Name*
Species*
Breed*
Age*
Sex*
Spayed/Neutered?*

YesNo
Why are we examining your pet today?*
What symptoms are you seeing, when did they begin, how frequently are they occurring? *
What do you feed your pet, and when did your pet last eat or drink? (includes treats, medications, etc.)?*
What medications, supplements, and/or over the counter products are you currently using for your pet? (please include heartworm/flea/tick/parasite prevention)?*
Are there any other services Lake Pine Animal Hospital can provide for your pet at this visit? There will be an additional charge for these services.*

BathNail TrimAnal Gland ExpressionEar CleaningMicrochippingClip Matted Hair
I, the undersigned owner or authorized agent of the above patient, hereby authorize the doctors of Lake Pine Animal Hospital to administer necessary treatment and to perform medical procedures. I further understand that no guarantee of successful therapeutic or diagnostic outcome is made. I also assume financial responsibility for all charges incurred, and agree to pay all charges at the time of release. I authorize an initial exam to be performed and understand that a doctor or staff member will call me with an estimate to proceed with diagnostics or treatment.*

I Accept
If I am unable to be reached by the phone number(s) I have provided I authorize doctors of Lake Pine Animal Hospital to perform initial diagnostic and therapeutic procedures up to:*
Please enter the total amount in dollars. Charges may include but are not limited to exam, bloodwork, radiographs, fluid therapy, medications for the treatment of symptoms, etc.
All pets being cared for in our facility must be current on all required vaccinations and free of fleas and ticks, or they will be treated at the owner’s expense. Required vaccines for dogs are Bordetella, Rabies, DHPP, and for cats they are FVRCP and Rabies.*

I understand
Contact Number For Today*
Date*

MonthDayYear
Owner/Authorized Agent Signature*

Clear
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.*
Should be Empty: