Drop-off Consent Form

patient_id

client_id

What will we be seeing your pet for today?

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Was your pet fed today?

Has your pet been seen by another veterinarian for treatment?

May we call them for records?

I authorize testing and treatment of my pet as deemed necessary by the veterinarian, and accept all charges

Please call me with an estimate before performing any procedures outside of the initial exam. If I cannot be reached, I authorize additional treatments deemed necessary by the veterinarian.

Please call me with an estimate before performing any procedures outside of the initial exam. I understand that if I cannot be reached, my pet will receive NO treatments except in the case of an emergency.

I agree to CPR being performed in case of arrest

I elect a “Do Not Resuscitate” status in case of arrest

	Increased	Decrease	No Change
Drinking
Appetite
Urination (Peeing)
Defecation (Pooping)
Weight

Drop-off Consent Form

Pet owner name

Pet name

Primary phone number

Alternate phone number

What will we be seeing your pet for today?

How long have these symptoms been going on?

Has your pet had an increase or decrease in any of the following?

Was your pet fed today?

Is your pet current on their rabies vaccinations?

Date given

Any previous illness/surgery?

List of pet’s current medications:

Time of Last Dose Given

Is your pet on any flea/tick/heartworm medications (list)?

What is your pet’s diet?

Has your pet been seen by another veterinarian for treatment?