Drop off Authorization Form

Drop off Authorization
Client Name*
First Last
Address*
Street Address Address Line 2 City State Zip Code
Telephone*
Name*
Species*
Breed*
Sex*
Color*
Markings*
Birth Date*
MM
DD
YYYY
What is the best phone number to reach you at today?
Name*
Phone*
What is a secondary number in case we cannot reach you?
Name
Phone
Why are you bringing your pet in today?
What is the earliest you are available to pick your pet up? (Please Note: pet may NOT be ready to go at this time)

: HH

MM
Please check the significant symptoms that apply to your pet
Vomiting*
- Yes
- No
Date Started
How Frequently?
Diarrhea*
- Yes
- No
Date Started
How Frequently?
Coughing*
- Yes
- No
Date Started
How Frequently?
Sneezing*
- Yes
- No
Date Started
How Frequently?
Shaking head*
- Yes
- No
Date Started
How Frequently?
Scratching ears*
- Yes
- No
Date Started
How Frequently?
Scooting*
- Yes
- No
Date Started
How Frequently?
Itchiness*
- Yes
- No
Date Started
Rate on a scale of 1 (least) to 10 (most)
Weight loss*
- Yes
- No
Date Started
Estimated previous weight
Limping/Lameness*
- Yes
- No
Date Started
(check all that apply)
- Left-Front
- Left-Rear
- Right-Front
- Right-Rear
Nasal discharge*
- Yes
- No
Date Started
Color
Eye discharge*
- Yes
- No
Date Started
Color
Hair loss*
- Yes
- No
Date Started
Location
Has there been a change in any of the following?
Appetite*
Water Consumption*
Frequency of Urination*
Energy Level*
When was the last time your pet ate?*
What diet do you feed?*
Have there been any recent changes in diet?*
If so what brand were you previously feeding?
Does your pet have any swelling, lumps, bumps, cuts or sore that you would like us to check?*
If yes, where they are located? (please be specific)
Where does your pet spend his/her time?*
Is your pet currently receiving heartworm prevention on a monthly basis?*
Has your pet ever had a reaction to any medication?*
If yes which one?
Is your pet on any other medications?*
Please list medication and daily doses

PAYMENT IS DUE IN FULL AT THE TIME SERVICES ARE RENDERED

I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). Return check fee is $25. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided.

To prevent the spread of infectious disease and parasites all in-patients, out-patients, boarders and grooming pets must be current on all vaccines and be free of parasites. I understand this to be the strict policy of the clinic and authorize the doctors to provide my pet or pets with vaccinations and parasite control as needed.
Client Signature*
Date*
MM
DD
YYYY

REVIEW BEFORE SUBMIT
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Phone
This field is for validation purposes and should be left unchanged.

Step 1 of 3

Drop off Authorization

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