Patient Intake and Consent Form: Drop Off Admission

Patient Intake and Consent Form: Drop Off Admission

Thank you for dropping your pet off with us today! Please complete the following form so we can best assess your pet's needs and contact you regarding medical care.
Owner Name *

First Name Last Name
Patient Name: *
Make/Model/Color of the Vehicle You are Driving Today: *
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? *
What is the best phone number to reach you TODAY to discuss your pet's care? *

Area Code Phone Number
Email *
example@example.com
What is the best way for us to contact you today? *

Phone Text Email
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: *
Who are we authorized to release your pet to other than you? *
Are you leaving any items with your pet (leash/collar/etc)? If so, please describe: *
Patient History:
What problem is your pet experiencing? *
When did the problem start? *
Is the problem the same, better, or worse? *
Has a similar problem happened in the past? If so, when? *
What is the pet's current diet (including treats)? Please specify brand, if known. *
How often is your pet fed? *

Once Daily Twice Daily Free Choice (Food available at all times)
Have you noticed any changes in your pet's appetite? *

Increase Decrease No Change
What human food has your pet recently enjoyed? *
Have you noticed any weight changes in your pet? *

Increase Decrease No Change
Any changes in water consumption/thirst? *

Increase Decrease No Change
Any increase in urination or accidents in the home? *

Increase Decrease No Change
Any change in bowel movements? *

Increase (Diarrhea) Decrease (Constipation) Normal / No Change Unsure
What most accurately represents your pet's lifestyle *

Inside exclusively (uses litter box or potty pads for eliminations) Outside exclusively Inside and Outside
If your pet has access to the outdoors, is it: *

Outside supervised on a leash Outside unsupervised - in a fenced area Outside unsupervised - free roaming without fence Pet never leaves the home
Date of most recent vaccinations: *
Use best estimate if exact date is unknown
Date of most recent heartworm test: *
Use best estimate if exact date is unknown.
Date of most recent intestinal de-worming treatment: *
Use best estimate if exact date is unknown.
Date of most recent labwork (CBC, Chemistry, etc): *
Use best estimate if exact date is unknown.
Is your pet receiving monthly flea and tick prevention? *

No Yes
If YES, when was your last dose of flea and tick prevention given? *
If YES, what brand of flea and tick medication are you using? *
Is your pet receiving monthly heartworm prevention? *

No Yes
If YES, when was the last dose of heartworm medication administered? *
If YES, what brand of heartworm medication are you using? *
Are you interested in learning about the once-a-year heartworm preventative injection for dogs (Proheart 12)? *

No Yes My dog is already using this
Is your pet on any prescription medications? If so, what? *
Is your pet receiving any over-the-counter supplements (vitamins, joint support, CBD, essential oils, etc)? *
Any other important medical history?
Does your pet have any known behavior problems or aggression issues (biting, separation anxiety, etc) that we should be aware of prior to exam? *
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.
Consent for Procedure:
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: *

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
If you are requesting vaccinations, please indicate your pet's needs *

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 Sick Patient - Administer Vaccines Only if Approved by Doctor
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: *

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:
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.
Signature of Owner/Agent *

Clear
Date

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Patient Intake and Consent Form: Drop Off Admission

Patient History:

Consent for Procedure: