Drop-Off Form Drop-Off Form Owner Name* First Last Date* MM slash DD slash YYYY Patient Name*Breed*Age*Best Phone number for today*When did problem begin?*has this been treated before?* Yes No Is the Patient currently on Medications NOT prescribed at our clinic ?* Yes No Please list medications*Appetite* Normal Increased Decreased For how long?*Vomiting?* Yes No Liquid or Food?How Long?Diarrhea?* Yes No How Long?Drinking* Normal Increased Decreased For how long?*Lethargic?* Yes No How Long?Coughing?* Yes No How Long?Gagging?* Yes No How Long?Urination* Normal Increased Decreased For how long?*Scratching?* Yes No How Long?Limping?* Yes No Where?*How Long?*Painful?* Yes No Where?*How Long?*Shaking Head?* Yes No Do you know why?*How Long?*Lumps or Bumps you’re concerned about?* Yes No Where?*Weight Loss/Gain?* Yes No When did you first notice?*Behavioral Changes?* Yes No How long?*Anything else the Dr. may need to know?Some pets require sedation for exams or painful procedures. May we sedate your pet if necessary?* Yes No Some pets require sedation for exams or painfAfter the exam may we proceed with further testing or treatments recommended by the Dr.?* Yes No Would you like us to call you first before these procedures or testing?* Yes No Owner ReleaseI understand that all precautions will be taken against injury, escape, or death of my pet. The hospital and staff will NOT be held liable for any problems that develop provided reasonable care and precautions are followed. I understand that ANY problem that develops with my pet while I am absent will be treated as deemed best by staff veterinarians and I assume financial responsibility for the treatments involved.* I understand Signature* Δ
