Mother Lode Veterinary Hospital Drop-Off Information and Consent for Treatment

Date*

Date

Client Name*

First NameLast Name

Contact Number*

Please enter a valid phone number.

Additional Contact Number

Please enter a valid phone number.

Patient Name*

Though we prefer to be able to speak to you directly regarding your pets health, we understand that with certain circumstances a drop-off appointment may be necessary. Please fill out the following information to completion in order to help us best assess and care for your pet. The contact number(s) listed above will be used for any additional information, follow-up, and notice of pick-up time. Please make sure you are available by phone in a timely manner so our staff can promptly obtain necessary information. If this is not possible, please indicate a party in which you give consent to authorize treatment.

Reason for visit:*

When did the symptoms begin (please list any and all symptoms and observations)?*

Any signs of coughing, sneezing, vomiting, diarrhea?*

YesNo

If you selected YES, please indicate:

Has your pet had any exposure to other animals (dog parks, boarding facilities, groomers, etc.)?*

YesNo

Has your pet been eating and drinking normally?*

YesNo

If you selected NO, for how long?

Has your pet eaten today?*

YesNo

If you selected YES, what time did they eat?

Is your pet currently on any medications?*

YesNo

If you selected YES, please list medications and the last time each medication was given.

Does your pet have any allergies or sensitivities to medications?*

YesNo

If you selected YES, please indicate:

Is your pet on heartworm prevention?*

YesNo

Is your pet on flea/tick prevention?*

YesNo

Are there any additional areas of concern you would like us to address today? If yes, please list all symptoms and observations.

Examination/work-up for your pet today may include x-rays, blood work, and/or sedation. Are there any services to which you object?*

YesNo

If you selected YES, which service to you object?

X-raysBlood workSedationOther

Following a complete exam and work-up, would you like our office to contact you with an estimate before any treatment is started?*

YesNo

If treatment requires anesthesia, do you give permission for your pet to placed under anesthesia with observation by a doctor/technician and do you understand the risks associated with the procedure?*

YesNoNot applicable

I have additional questions relating to anesthetic procedures and request a call from the treating doctor prior to anesthetic procedures.*

YesNo

If we are unable to reach you, do you give permission to continue treatment?*

YesNo

If you selected YES, up to what dollar amount do you authorize?

In case of an emergency, or in the case that you are unreachable, please indicate a person(s) you authorize to consent to treatment in your absence. Please include NAME and PHONE NUMBER.

I verify that I am 18 years of age or older and I hereby authorize the veterinarian to examine, treat, and prescibe for the above described pet. I assume responsibility for all charges incurred in the treatment of this pet and understand that all charges are to be paid at the time of pick-up.

Owner Signature:*

All animals must be picked up before closing. Our office is open Mon-Fri 8am-5:30pm unless otherwise indicated.

Please feel free to add any additional comments or concerns in this section.