Drop Off Veterinary Visit Form

Client(Required)







Sex(Required)


Species




Are you the pet's primary caregiver?(Required)


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?(Required)


Have you noted any Sneezing?(Required)


Have you noted any Vomiting?(Required)


Have you noted any Diarrhea?(Required)


Have you noted changes in Appetite?(Required)





Have you noted changes in Water Consumption?(Required)





Have you noted changes in Urination?(Required)





Have you noted changes in Behavior / Activity?(Required)





Does your pet go outside at all?


Does your pet travel with you outside of NC or to the coast or mountains?(Required)


Other services desired at additional cost:





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



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



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



*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?(Required)


Pick Up(Required)


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!)(Required)



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