Drop Off for Veterinary Visit Form in Durham & Chapel Hill, NC | Falconbridge Animal Hospital & Village Veterinary Hospital

Client*

First Last

Patient*

Sex*

M
F

Approximate DOB or Age*

Species*

Canine
Feline

Breed*

Reason for visit and any recent problems/changes:*

Are you the pet's primary caregiver?*

Yes
No

I understand that current Wellness Exams, Distemper, and Rabies vaccines are required for all pets, as well as Parvo, Bordetella, Flu Vaccine (H3N2), and a Fecal Flotation for dogs before admission to the hospital. Pets not current on vaccines/testing will be updated as long as it is deemed safe and advisable by a veterinarian. I understand that I am responsible for associated costs.

I certify that to the best of my knowledge my pet is free of all external parasites upon signing this release. If parasites, such as fleas or ticks, are found, I understand that my animal will be treated on admission for an additional cost.

Have you noted any Coughing?*

Yes
No

Have you noted any Sneezing?*

Yes
No

Have you noted any Vomiting?*

Yes
No

Have you noted any Diarrhea?*

Yes
No

If you answered yes to any of the conditions above please explain here

Have you noted changes in Appetite?*

Increase
Decrease
None

Have you noted changes in Water Consumption?*

Increase
Decrease
None

Have you noted changes in Urination?*

Increase
Decrease
None

Have you noted changes in Behavior / Activity?*

Increase
Decrease
None

If you did NOT answer "none" to any the conditions above please explain here

Does your pet go outside at all?

Yes
No

Supervised?

Yes
No

Does your pet travel with you outside of NC or to the coast or mountains?*

Yes
No

What diet is your pet currently eating and how much are you feeding??*

What medications (including heartworm and flea/tick prevention) is your pet currently taking?*

Other services desired at additional cost:

Nail trim ($18.00)
Anal Gland Expression ($24.00)
Microchip Identification ($46.00)

If vet recommended, we may need to perform labwork that can range from $64 to $217 depending on symptoms.*

Yes, please run the tests
No, not at this time
Please call first*

If vet recommended, we may need to perform other diagnostic testing, such as x-rays which can vary in price*

Yes, please run the tests
No, not at this time
Please call first*

Some pets, and some procedures, benefit from sedation. Should this apply to your pet, do you authorize sedation to be used today?*

Yes
No, not at this time
Please call first*

If yes, when did your pet last eat?

*If you are unavailable at the phone number given, we will proceed at the doctor's discretion.

Is it ok to give your pet treats while he/she is here?*

Yes
No

Pick Up*

Please call me when my pet is ready to be picked up; I know this will likely be after 4:00pm.
I plan to pick up my pet between 4:30 and 5:30pm; there is no need to call me when you are done.

Falconbridge & Village Vets can use my pet's photos on FalconbridgeAnimal.com and their social media pages. (Like us on Facebook & follow us on lnstagram!)*

Yes
No

Signature of Owner or Agent*

Phone number on day of appointment*

Date signed*

Phone

This field is for validation purposes and should be left unchanged.