Patient Intake and Consent Form: Drop Off Admission

1
Owner Name* This field is required.
First Name
Last Name
2
Patient Name:* This field is required.
3
Make/Model/Color of the Vehicle You are Driving Today: * This field is required.
4
We will need to be able to contact you or someone with permission to make medical and financial decisions, who will we be speaking with today?* This field is required.
5
What is the best phone number to reach you TODAY to discuss your pet's care?* This field is required.
Area Code
Phone Number
6
Email* This field is required.
example@example.com
7
What is the best way for us to contact you today?* This field is required.
Phone
Text
Email
8
We will do our best to accommodate your pick up schedule, please indicate if you need to pick up your pet by a specific time today:* This field is required.
9
Who are we authorized to release your pet to other than you?* This field is required.
10
Are you leaving any items with your pet (leash/collar/etc)? If so, please describe:* This field is required.
11
What problem is your pet experiencing?* This field is required.
12
When did the problem start?* This field is required.
13
Is the problem the same, better, or worse?* This field is required.
14
Has a similar problem happened in the past? If so, when?* This field is required.
15
When was the last time your pet ate?* This field is required.
16
What is the pet's current diet (including treats)? Please specify brand, if known.* This field is required.
17
How often is your pet fed?* This field is required.
Once Daily
Twice Daily
Free Choice (Food available at all times)
18
Have you noticed any changes in your pet's appetite?* This field is required.
Increase
Decrease
No Change
19
What human food has your pet recently enjoyed?* This field is required.
20
Have you noticed any weight changes in your pet?* This field is required.
Increase
Decrease
No Change
21
Any changes in water consumption/thirst?* This field is required.
Increase
Decrease
No Change
22
Any increase in urination or accidents in the home?* This field is required.
Increase
Decrease
No Change
23
Any change in bowel movements?* This field is required.
Increase (Diarrhea)
Decrease (Constipation)
Normal / No Change
Unsure
24
What most accurately represents your pet's lifestyle* This field is required.
Inside exclusively (uses litter box or potty pads for eliminations)
Outside exclusively
Inside and Outside
25
If your pet has access to the outdoors, is it:* This field is required.
Outside supervised on a leash
Outside unsupervised - in a fenced area
Outside unsupervised - free roaming without fence
Pet never leaves the home
26
Date of most recent vaccinations:* This field is required.
Use best estimate if exact date is unknown
27
Date of most recent heartworm test:* This field is required.
Use best estimate if exact date is unknown.
28
Date of most recent intestinal de-worming treatment:* This field is required.
Use best estimate if exact date is unknown.
29
Date of most recent labwork (CBC, Chemistry, etc):* This field is required.
Use best estimate if exact date is unknown.
30
Is your pet receiving monthly flea and tick prevention?* This field is required.
No
Yes
31
If YES, when was your last dose of flea and tick prevention given?* This field is required.
32
If YES, what brand of flea and tick medication are you using?* This field is required.
33
Is your pet receiving monthly heartworm prevention?* This field is required.
No
Yes
34
If YES, when was the last dose of heartworm medication administered?* This field is required.
35
If YES, what brand of heartworm medication are you using?* This field is required.
36
Are you interested in learning about the once-a-year heartworm preventative injection for dogs (Proheart 12)?* This field is required.Only available for dogs over 1 year of age.
No
Yes
My dog is already using this
37
Is your pet on any prescription medications? If so, what?* This field is required.
38
Is your pet receiving any over-the-counter supplements (vitamins, joint support, CBD, essential oils, etc)?* This field is required.
39
Any other important medical history?
40
Does your pet have any known behavior problems or aggression issues (biting, separation anxiety, etc) that we should be aware of prior to exam?* This field is required.An additional handling fee or sedation charge could be required. If sedation and anesthesia is declined, we may be unable to safely examine or treat your pet.
41
I am the owner or agent for the above named animal and have the authority to execute this consent. I hereby consent and authorize the following as needed for the veterinarian to diagnose and treat the above named animal:* This field is required.
Physical Examination
Flea/Tick Treatment (required at your expense if your pet is found to have fleas or ticks)
Sedation or Anesthesia
Radiographs
Laboratory Testing / Bloodwork / Urinalysis
Vaccinations
Medications
Ultrasound
Hospitalization
All of the Above
42
If you are requesting vaccinations, please indicate your pet's needs* This field is required.
Rabies
DHLPP (Distemper/Parvo/Lepto/Parainfluenza) - dog only
Bordetella / Kennel Cough - dog only
Canine Influenza Bivalent - dog only
Feline Leukemia and FVRCP (Calici/Rhinotracheitis/Chlamydia) - cat only
No Vaccines Needed - All Up To Date and Can Provide Records
Sick Patient - Administer Vaccines Only if Approved by Doctor
43
In using this drop-off form, I realize that IT IS ESSENTIAL THAT I BE AVAILABLE BY PHONE (not voicemail) so that the doctor can best help me and my pet. If I am not available, I understand that the doctor will proceed as directed below:* This field is required.
Do nothing beyond basic physical examination until I can authorize treatment based on an estimate.
Do what he feels is medically necessary to treat and diagnose my animal.
Do what he feels is medically necessary to treat and diagnose my animal not to exceed the amount listed below:
44
I, the undersigned owner or authorized agent of the above patient, hereby authorize the Doctors of the Animal Clinic of West Plains, Inc. to administer necessary treatment and 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, unless other arrangements have been made PRIOR to admission to the Clinic and PRIOR to treatment of the above described animal. Payment is accepted by cash, check, credit card, or CareCredit. We are not responsible for any acts of God that may occur while your pet is staying with us.
45
Signature of Owner/Agent* This field is required.
Clear
46
Date
Date
Month
Day
Year
Should be Empty: