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Drop Off Form
Cancelation policy
Deposits are required to reserve an appointment slot for all new clients and pets with an annual exam that is overdue. At the time of the appointment, this deposit will be used to cover the examination fee. Cancelations must be made three hours prior to appointment time. The deposit will be applied to the rescheduled appointment. Failure to call three hours prior to appointment will result in forfeiture of deposit. In order to be fully refunded, a 24-hour notice must be given prior to the scheduled appointment cancelation.
Name
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First
Last
Phone
*
Email
*
Pet Name
*
ADMIT SICK PET FOR THE DAY
What are your primary concerns?
*
How long has this been a problem?
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Is this a recurring problem? If so, when was the last episode?
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Has your pet seen another veterinarian for this problem?
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If so, what was the treatment?
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Have you done any treatment/medicating at home for this problem? Yes or No - if so, what?
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Is your pet on any medications? If so, please list which ones and how often they are given.
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Appetite?
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Normal
Abnormal
Please explain any abnormalities:
*
Water consumption?
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Normal
Abnormal
Please explain any abnormalities:
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Has your pet had access to food or water since 10 pm last night?
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Yes
No
What diet is your pet on?
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Treats
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Table Food
*
Has there been any vomiting?
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Yes
No
Please Describe:
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Has there been any diarrhea?
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Yes
No
Please Describe:
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Has there been any coughing?
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Yes
No
Please Describe:
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Has there been any sneezing?
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Yes
No
Please Describe:
*
Has your pet's activity increased/decreased? Yes or No - Please explain:
*
Describe your pet's urination.
*
Normal
Increased Frequency
No Urinating
Decreased Frequency
Abnormal Color
Do you want laboratory tests done if necessary?
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Yes
No
Do you wish to set a dollar limit? If so, what?
*
In the event of a respiratory or cardiac emergency, please choose an advanced directive for your pet. Please keep in mind, if emergency procedures are performed, they will result in additional charges for the treatment or medications that are administered in this circumstance.
I DO want lifesaving procedures performed on my pet, as necessary.
I DO want lifesaving procedures performed on my pet, as necessary. I understand and acknowledge my consent.
I DO NOT want lifesaving procedures performed on my pet.
I DO NOT want lifesaving procedures performed on my pet. I understand and acknowledge my non-consent.
FULL PAYMENT IS DUE AT THE TIME OF PICKING UP YOUR PET. PLEASE CHECK BELOW THAT YOU COMPLY:
*
I agree to the payment policy.
Today's Date
Date Format: MM slash DD slash YYYY
About Our Hospital
Location & Hours
About Our Hospital
Team
New Client Registration Form
Drop Off Form
Quality of Life Guide
Green Acres Blog
Leave A Review
Client Code of Conduct
Services
Anesthesia and Patient Monitoring
Reproductive Services
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Wellness and Vaccination Programs
Boarding
Microchips
Cremations
Pet Health
Pet Health Library
Pet Health Checker
Pet Insurance Info
How-To Videos
Online Store
CareCredit
Scratchpay
PetDesk