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General Drop Off Form

Pet Name:

*

Date:

*

Primary Reason for Visit:

*

Estimate Needed?

*

Estimate Needed?

A

Yes

B

No

Estimate Given?

*

Estimate Given?

A

Yes

B

No

Vaccines Needed:

*

Vaccines Needed:

A

Yes

B

No

**Please note a 3yr Rabies vaccine can only be given if vaccine is not overdue (even by one day). A 3yr DHPP and a 3yr Rabies vaccine will not be given together.**

Dog:

*

Dog:

1yr Rabies

3yr Rabies

1yr DHPP

3yr DHPP

Bordetella

Lepto

Fecal

ABC

HW Occult

ProHeart 6

Flu N2

Flu N8

Cat:

*

Cat:

Rabies

FVRCP

Leukemia

Fecal

ABC

HW

Occult

Grooming Needed:

*

Grooming Needed:

A

Yes

B

No

*Dog MUST be up to date on Rabies, DHPP, Bordetella, Fecal and Flu Combo Vaccines. Cats MUST be up to date on Rabies and FVRCP vaccines.**

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Bath

*

Shave

Nail Trim

Must Sedate

Express Anal Glands

Other

Notes:

*

Diagnostics/Services: After physical exam, PPHC has permission to do the following diagnostics/services without giving estimate or calling first:

*

Diagnostics/Services: After physical exam, PPHC has permission to do the following diagnostics/services without giving estimate or calling first:

Skin Scraping

Ear Swab/Ear Cleaning

Urinalysis

Fecal/Fecal Direct

X-Rays

Aspirate/Cytology

Bloodwork

Anything that is needed

Other

I need an estimate before any diagnostics/services are done.

Products Need To Go Home:

*

Products Need To Go Home:

Trifexis

Bravecto

Sentinel

Revolution (available for cats only)

Single

6 Mo.

12 Mo.

Other Supplies

Additional Notes/Information:

*

Signature:

*

Signature

Phone # To Call First:

*

Phone # To Call Second:

*