Pet Drop-Off Form

Owner's Name:*

First Last

Phone:*

Pet's Name:*

Reason for today's visit:*

If sick, for how long?

Pet's normal diet:*

Prescription
Commercial
Table Scraps

Meals per day?*

Last time your pet ate?*

: HH

MM

Your pet is:*

Indoor
Outdoor
Both

Please answer the questions below. If Yes, please provide details.

Heartworm preventative?*

Yes
No

If yes, what type and date of last dose?

Flea/tick preventative?*

Yes
No

If yes, what type?

Current medications?*

Yes
No

If yes, what?

Any known allergies?*

Yes
No

If yes, what?

Recent injury or surgery?*

Yes
No

If yes, what?

Lack of energy and/or weakness?*

Yes
No

If yes, explain.

Behavioral changes?*

Yes
No

If yes, explain.

History of seizures?*

Yes
No

Eye, ears, nose, mouth discharge?*

Yes
No

If yes, explain.

Coughing, sneezing or gagging?*

Yes
No

If yes, explain.

Appetite increase or decrease?*

Yes
No

If yes, explain.

Vomiting and/or diarrhea or constipation?*

Yes
No

If yes, explain.

Any scooting on rear?*

Yes
No

Drinking more or less than usual?*

Yes
No

If yes, explain.

Urinating more or less than usual?*

Yes
No

If yes, explain.

Limping?*

Yes
No

If yes, which leg?

Scratching and/or chewing at skin?*

Yes
No

If yes, explain.

Any lumps or bumps on body?*

Yes
No

If yes, where?

A complete physical exam will be performed on every pet.

Please check the additional services you request today:

Nail trim
Express anal glands
Intestinal parasite check (fecal)
Heartworm test
Feline Leukemia/FIV/Heartworm Ag Test
Update necessary vaccines

I authorize sedation or pain relief for the exam or treatment if needed ($33-$55).*

Yes
No
Call first

Electronic Signature

Date

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