Hospital Drop Off Form

Best Contact Number:(Required)

Email(Required)

Owner Name(Required)

First Last

Pet's Name(Required)

Date of Scheduled Appointment(Required)

Known Medical Conditions:

What is the primary concern/ What are the symptoms?

Is this the first time your pet has had this issue?

Yes

If yes, when did it start?

If no, did the veterinarian treat the problem or did the problem go away?

Treated

Went Away

Is your pet allergic to any medications?

Yes

If yes, which medications?

Please list all medications your pet is currently on: (Example: Novox 25mg, give 1 tablet by mouth twice daily, last given on 08/05/2022 at 9:00am)

Please read the following and check one box below:(Required)

I authorize the veterinarian to examine my pet and perform diagnostic tests and treatment not exceeding $350.

I authorize diagnostic tests and treatment as recommended by the veterinarian without telephoning me.

I authorize the veterinarian to examine my pet. Call me at the number I provided at the beginning of this form to discuss diagnostic testing and/or treatment. I understand that the veterinarian will not proceed with diagnostic testing or treatment without my authorization.

By signing this form, I acknowledge that I am responsible for and/or am authorized to make decisions in regard to the above listed pet’s medical care.

Signature(Required)

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Hospital Drop Off Form

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