Pet Drop-Off Form

Owner's Name:*

First Last

Pet's Name:*

Email*

Reason for today's visit:*

If sick, for how long?

Pet's normal diet:*

Prescription
Commercial
Table Scraps

What Brand?

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

What type of heartworm preventative and date of last dose?

Flea/tick preventative?*

Yes
No

What type of flea/tick preventative?

Current medications?*

Yes
No

What medication(s)?

Any known allergies?*

Yes
No

What allergies?

Recent injury or surgery?*

Yes
No

What injury or surgery?

Lack of energy and/or weakness?*

Yes
No

Please explain.

Behavioral changes?*

Yes
No

Please explain.

History of seizures?*

Yes
No

Eye, ears, nose, mouth discharge?*

Yes
No

Coughing, sneezing or gagging?*

Yes
No

Change in appetite?*

Yes - increase.
Yes - decrease.
No

Vomiting and/or diarrhea or constipation?*

Yes
No

Please explain.

Any scooting on rear?*

Yes
No

Drinking more or less than usual?*

Yes - more.
Yes - less.
No

Urinating more or less than usual?*

Yes - more.
Yes - less.
No

Limping?*

Yes
No

Which leg?

Scratching and/or chewing at skin?*

Yes
No

Please explain.

Any lumps or bumps on body?*

Yes
No

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 ($55-$100).*

Yes
No
Call first

Do you need any preventatives today?

Yes
No

Does your pet have access to ponds, livestock, wooded areas, get groomed, or go to dog parks?

Yes
No

Comments:

Electronic Signature*

Best Contact Phone Number:*

Date*

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