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Drop Off Veterinary Visit Form

"*" indicates required fields

Client*

First

Last

Patient*

Sex*

Male

Female

Approximate DOB or Age*

Species

Canine

Feline

Other

Breed*

Reason for visit and any recent problems/changes:*

Are you the pet's primary caregiver?*

Yes

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.

I understand there is no overnight supervision if needed to spend the night at the hospital.*

Please type your initials.

Have you noted any Coughing?*

Yes

Have you noted any Sneezing?*

Yes

Have you noted any Vomiting?*

Yes

Have you noted any Diarrhea?*

Yes

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

Have you noted changes in Appetite?*

Increase

Decrease

None

Other

Have you noted changes in Water Consumption?*

Increase

Decrease

None

Other

Have you noted changes in Urination?*

Increase

Decrease

None

Other

Have you noted changes in Behavior / Activity?*

Increase

Decrease

None

Other

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

Does your pet go outside at all?*

Yes

If yes, supervised or unsupervised?

Supervised

Unsupervised

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

Yes

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 ($25.00)

Microchip Identification ($48.00)

Other

If vet recommended, we may need to perform labwork that can range from $91 to $280 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, please run the tests

No, not at this time

Please call first*

*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

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

Signature of Owner or Agent*

Phone number on day of appointment*

Date Signed*

MM slash DD slash YYYY

Name

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