Patient Drop-Off Questionnaire

Date of Drop-off *

Date

DVM *

Owner's Name *

First Name Last Name

Pet's Name *

Reason for drop-off *

Anesthetic Procedure General Exam Emergency Drop-off

How do you think your pet is doing? *

Do you have any other concerns you would like the doctor to address? *

Pet's normal diet: *

Last feeding time: *

Please note if your pet is experiencing any of the following:

Diarrhea Vomiting Lethargy

Will your Pet need to be given medication while they are in Hospital? *

Yes No

Medications: *Please provide any medications that may be needed *

Who shall we call when your pet is ready? *

First Name Last Name

Phone Number *

Area Code Phone Number

Pick-up request time/availability: *

Is the above person the best contact and phone number to call when your pet is ready? *

Yes No

In the event of an emergency, who can we reach with regard to any questions? *

First Name Last Name

Phone Number *

Area Code Phone Number

Consent

I, the undersigned owner or agent of the owner, hereby consent to the examination of my pet by Lyndhurst Animal Clinic (LAC). I agree that after consultation with me, the clinic's Doctors may prescribe medication for, treat, hospitalize, anesthetize and or perform surgery on my pet.

I understand that no guarantee can be made as to the outcome of treatment and that I am encouraged to discuss any concerns I have about the risks of treatment with the attending Veterinarian before any procedures or treatment is initiated.

I understand that a treatment plan including an estimate of the costs for Veterinary Services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during my pet's ongoing medical treatment.

I hereby authorize the name(s) above to make financial and medical decisions for the patient listed. I understand the professional fees are to be paid at the time services are rendered and a deposit is required on all pets admitted to the hospital.

I understand that I (the owner or agent) am financially responsible to LAC for all charges relating to this patient. I have read and agree to the treatment authorization. I have also read and accept the financial obligations.

I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT FORM *

Yes, I give LAC consent to treat my pet No, I do not give LAC consent to treat my pet

Signature *

Clear

Patient Drop-Off Questionnaire

Contact Information

Treatment Consent