DROP-OFF RELEASE

Owners Name:*

Pet Name:*

Date of Appointment*

Date

Phone number to reach you at today*

Would you like to receive updates via text messaging?*

YesNo

Do you give us permission to share your pet(s) on social media?*

YesNo

Reason for today's drop off:*

0/330

Other concerns today:*

0/220

Has appetite and water consumption been normal?*

If no, please explain.

What food is your pet on?*

Time of last meal:*

Have you noticed:*

	Yes	No	How often?	Since when?
Diarrhea
Vomiting
Weight loss
Weight gain

Is your pet lethargic*

Since when?

Has your pet eaten any foreign material?*

What and when?

What medication (if any) is your pet taking?

	Name of medication:	Amount given:	Time given:

The veterinarian will perform a thorough physical exam as soon as the schedule allows. For the benefit of your pet's health, it is important to start treatment as soon as possible.

Would you like us to:*

Treat your pet after examination?Call you with the findings of the examination and an estimate of treatment cost prior to our treating your pet?

*Please note that if we have not seen your pet before, we will need to be able to contact you regarding your pet's examination prior to starting any treatments.

If I cannot be reached at the number provided, I authorize initial diagostics, including radiographs and bloodwork if indicated for my pet. Further, if I cannot be reached, I authorize initial treatment, including fluid support and other supportive medications be started as indicated for my pet.

I understand payment is due when my pet is discharged, however, a deposit may be required after an estimate is prepared and discussed. I accept financial responsibility for charges incurred for this pet.

I am the owner/ agent for described animal, authorize, and request an exam for my pet. I am of legal age.

Signature of Owner*