Drop Off Form

Which practice would you like to register with?

Location

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Full Name * *

Pet's Name *

Phone Number *

Alternate Phone Number

Reason for today's visit *

Start date of clinical signs *

Diet

Medications

Attitude *

Bright & Alert
Depressed/Lethargic
Quiet

Appetite *

Increased
Decreased
Not eating at all
Unchanged

Water intake *

Unchanged
Decreased
Increased

Vomiting? If yes, how often? *

Diarrhea? If yes, how often, what consistency and what colour? *

Coughing *

Yes
No

Sneezing *

Yes
No

Allergies? If yes, please explain what your pet is allergic to *

Additional comments and requests

I AM THE OWNER OR AUTHORIZED AGENT OF THE ANIMAL PRESENTED FOR CARE. IF ANESTHESIA OR SEDATION IS REQUIRED, I UNDERSTAND, AND ACCEPT THAT THERE ARE ALWAYS INHERENT RISKS, INCLUDING DEATH. I ALSO AUTHORIZE THE CLINIC STAFF IN AN EMERGENCY SITUATION, TO FOLLOW THROUGH WITH SUCH PROCEDURES AS ARE NECESSARY FOR THE WELL BEING OF MY PET ON A CONTINUING BASIS UNTIL FURTHER COMMUNICATION WITH ME IS POSSIBLE (PLEASE NOTE THAT THE EXAMINATION FEE IS $110+ TAX AND AN ADDITIONAL $11.50 DROP OFF FEE MAY APPLY AND BY SUBMITTING THIS FORM YOU AGREE TO HAVE THE PET ADMITTED IN THE HOSPITAL AND EXAMINED BY A VETERINARIAN.) I UNDERSTAND THAT I AM RESPONSIBLE FOR THE COSTS OF ALL TREATMENTS PERFORMED TODAY AND PAYMENT IS DUE IN FULL WHEN I PICK MY PET UP LATER TODAY. PLEASE INITIAL IN BOX BELOW *

Security Question

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Drop Off Form

Instructions for Surgery or Dental Procedures

Which practice would you like to register with?

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