Drop Off for Veterinary Visit Form Client* First Last Patient*Sex*MFApproximate DOB or Age*Species*CanineFelineBreed*Reason for visit and any recent problems/changes:*Are you the pet's primary caregiver?*YesNoI 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?*YesNoHave you noted any Sneezing?*YesNoHave you noted any Vomiting?*YesNoHave you noted any Diarrhea?*YesNoIf you answered yes to any of the conditions above please explain hereHave you noted changes in Appetite?*IncreaseDecreaseNoneHave you noted changes in Water Consumption?*IncreaseDecreaseNoneHave you noted changes in Urination?*IncreaseDecreaseNoneHave you noted changes in Behavior / Activity?*IncreaseDecreaseNoneIf you did NOT answer "none" to any the conditions above please explain hereDoes your pet go outside at all?YesNoSupervised?YesNoDoes your pet travel with you outside of NC or to the coast or mountains?*YesNoWhat 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 testsNo, not at this timePlease 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 testsNo, not at this timePlease call first*Some pets, and some procedures, benefit from sedation. Should this apply to your pet, do you authorize sedation to be used today?*YesNo, not at this timePlease 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?*YesNoPick 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!)*YesNoSignature of Owner or Agent*Phone number on day of appointment*Date signed* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.