Client Drop Off Form 

Date: _______________

Client Name: ____________________________ 

Pet Name: ______________________________

Reason for Visit:

Please Explain: __________________________________________________________________________________

__________________________________________________________________________________

Did your pet eat today? If yes, when? _______________________________

Is your pet on Heartworm preventative?   Y/N

Is your pet on Flea/Tick preventative?   Y/N

Is your pet currently taking any medications?  Y/N

Name:____________________________ Dose/Frequency:__________________

Name:____________________________ Dose/Frequency:__________________

Is your pet taking any Over the Counter supplements?  Y/N

Name:____________________________Dose/Frequency:__________________

Has your pet shown any of the following symptoms?

Vomiting:   Y/N

Duration: ___________________________#times/day__________________

Vomited (please circle): Food Phlegm Bile Unknown Other________

Diarrhea:   Y/N

Duration: ___________________________ # times/day:_______________________

Stool contained (please circle): Mucus?/Blood?

Straining to have a Bowel Movement:  Y/N    Duration: _______________________

Straining to Urinate: Y/N   Duration: _____________________________

Coughing: Y/N   Duration: _____________________________________

Seizures: Y/N   Duration: ______________ Frequency:_________________________

Limping: Y/N  Duration: ______________ Which leg(s)? __________________

Unusual Lumps or Bumps: Y/N   First Noticed: ___________Where? __________

Listless, lethargic: Y/N 

 

If deemed medically necessary by the Doctor, I authorize the following care for my pet: 

Diagnostic Blood Work   Yes/No

Urinalysis   Yes/No

Radiographs (X-rays)   Yes/No

Sedation   Yes/No 

Emergency Contact Number: _______________________________________________

(Please provide the number you can be reached at immediately)

 

Signature: ________________________________ Date: _________________________