HPVC Drop-Off Form

Patient Drop-off Form

submits directly to hancockparkvet@gmail.com
Name*

First NameLast Name
Pet Name*
Reason for today's visit (Please note your pet is a DROP off, your pet will get seen in between appointments and the doctor will call you with an estimate and treatment plan for the visit):*
List Symptoms
Phone Number to best reach you*
Is your pet currently taking any medications, vitamins, supplements?*
Frequency and dosages of all medications taken in last 24hrs
Please select any other treatments you would like your pet to receive:

MicrochipNail TrimUpdate VaccinesBloodworkPrescription refillAnal glandsFlea MedicationFecal testOther
If in the unlikely event that life saving measures need to be taken while my pet is under the care of HPVC:*

I DO want any/all measure performed to save my petI do NOT want heroic measures taken to save my pet
Heroic measures may include oxygen treatment, IV fluids, addition medications, and/or CPR. Additional fees of at least $150 will be charged if this is necessary.

Again, in the rare event these measures are needed, we will contact you as soon as the pet is stable.
Please read:
We close at 6pm, latest pick up time is 5:30pm. If your pet is ready prior to 5:30pm we will let you know. We are in a residential area and cannot board pets overnight. Please make arrangements for your pet to be picked up before closing. There is no staff on premise overnight. A $25 fee will be added to charges if pet is not picked up by 6:15pm

Fees/Payment - It is understood that I shall be responsible for the costs in connection with any care and/or medical treatment related to the above issue and that payment shall be made in full, prior to the return of my pet to my care. I understand that any estimate of fees given for a trement plan are just that, an estimate, and that the cost to treat my pet may exceed expected treatment plants.

I certify that the above information is correct, and I understand that the information. By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully.
Name*

First NameLast Name
Date*

MonthDayYear
DateHourMinutesAM/PM Option
Signature*

Clear
Should be Empty:

Patient Drop-off Form

Please read: