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Drop off Authorization Form
Matt Hixon
2019-11-30T03:13:46-06:00
Step 1 of 3
33%
Drop off Authorization
Client Name
*
First
Last
Address
*
Street Address
Address Line 2
City
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State
Zip Code
Telephone
*
Name
*
Species
*
Breed
*
Sex
*
Male
Female
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
AM
PM
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)
1
2
3
4
5
6
7
8
9
10
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
*
No Change
Increased
Decreased
Water Consumption
*
No Change
Increased
Decreased
Frequency of Urination
*
No Change
Increased
Decreased
Energy Level
*
No Change
Increased
Decreased
When was the last time your pet ate?
*
What diet do you feed?
*
Have there been any recent changes in diet?
*
No
Yes
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?
*
No
Yes
If yes, where they are located? (please be specific)
Where does your pet spend his/her time?
*
Indoor Only
Mostly Indoor
Mostly Outdoor
Outdoor Only
Is your pet currently receiving heartworm prevention on a monthly basis?
*
Yes
No
Has your pet ever had a reaction to any medication?
*
Yes
No
If yes which one?
Is your pet on any other medications?
*
Yes
No
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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