Home Drop Off Agreement

Drop Off Agreement

Drop off Agreement

Thank you for allowing us to care for your pet! The following information will be used to help our veterinary team accurately complete your pet’s medical history for your pet’s visit. Please fill out this form in its entirety with as much information as you can provide. This form will greatly assist us in making sure we do not have any missing information regarding your pet and eliminates frequent, back-and-forth phone calls and failed communication efforts. By not filling out this form in its entirety you can expect delays to your pet’s visit, and we may not be able to complete all requested services in one visit, which will require an additional appointment and exam fee.

Client Name(Required)

Pets Name(Required)

Date of scheduled visit:(Required)

Contact number(Required)

Is your pet experiencing any of the following (check all that apply):

Abnormal/Decreased Eating(Required)

Yes

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Abnormal/Decreased Eating – Additional Details

When was the last time your pet ate normally?(Required)

Is your pet refusing all food or eating some things or smaller portions? Explain.(Required)

Has there been a change in diet?(Required)

Yes

What was your pet's previous diet and what is your pets' new diet?(Required)

When did this diet change occur?(Required)

Was the new diet introduced gradually or was it an immediate switch?(Required)

Does your pet eat table scraps, toys, or any other foreign materials?(Required)

Yes

Do you have knowledge of something your pet could have eaten recently?(Required)

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Section Break

Vomiting(Required)

Yes

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Vomiting – Additional Details

When did the vomiting start?(Required)

How often is your pet vomiting?(Required)

Is there any blood noted in the vomit?(Required)

Yes

Is your pet vomiting immediately after eating?(Required)

Yes

Does your pet eat table scraps, toys, or any other foreign material?(Required)

Yes

Do you have knowledge of something your pet could have eaten recently?(Required)

Has there been a change in diet?(Required)

Yes

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Has there been a change in diet? – Additional Details

What was your pets previous diet and what is your pets new diet?(Required)

When did this diet change occur?(Required)

Was the new diet introduced gradually or was it an immediate switch?(Required)

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Has there been a change in diet? – End

Stool Abnormalities/Difficulties(Required)

Yes

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Stool Abnormalities/Difficulties – Additional Details

Select all that apply:(Required)

Difficulty with defecation

Scooting

Constipation

Blood in Feces

Abnormal Odor/Color

Visible Worms in Feces

Unable to control feces/abnormal accidents in the house

Diarrhea

Other

Please describe the worms (Example: long spaghetti-like, grains of white rice, etc.)(Required)

Explain(Required)

When did your pet’s symptoms first occur?(Required)

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if Diarrhea is selected

When did the diarrhea start?(Required)

How often is your pet having diarrhea?(Required)

Is there any blood noted in the diarrhea?(Required)

Yes

Does your pet eat table scraps, toys, or any other foreign material?(Required)

Yes

Do you have knowledge of something your pet could have eaten recently?(Required)

Has there been a change in diet?(Required)

Yes

If yes, what was your pet previously eating and what did the diet change to and when?(Required)

Did you gradually change your pet's diet or was it an immediate change?(Required)

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Stool Abnormalities/Difficulties – End

Bad Breath(Required)

Yes

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Is your pet on a monthly flea prevention?(Required)

Yes

When was the last dose given?(Required)

Has it been prescribed at our hospital?(Required)

Does your pet have any known allergies?(Required)

Yes

Please list known allergies(Required)

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Scratching/Itching – End

Eye Problems(Required)

Yes

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Eye Problems – Additional Details

Select all that apply:(Required)

Redness

Pawing at the eyes

Decreased/Loss of vision

Inflammation

Clear Discharge

Green/Yellow/Crusty Discharge

Squinting

Other

Explain:(Required)

Please select one of the following:(Required)

Both Eyes

Patients Right Eye

Patients Left Eye

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Eye Problems – End

Ear Problems(Required)

Yes

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Ear Problems – Additional Details

Select all that apply:(Required)

Redness

Shaking Head

Decreased/Loss of hearing

Inflammation

Foul Odor

Green/Yellow/Crusty Discharge

Bleeding

Black discharge

Other

Explain:(Required)

Please select one of the following:(Required)

Both Ears

Patients Right Ear

Patients Left Ear

How long has your pet been experiencing trouble with the ears?(Required)

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Ear Problems – End

Coughing(Required)

Yes

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Coughing – Additional Details

How long has your pet been coughing?(Required)

Select all that apply:(Required)

Wet Cough

Dry Cough

Coughing with exercise

Coughing while at rest

Other

Other(Required)

Has your pet been to a grooming or boarding facility or around any new unvaccinated pets recently?(Required)

Yes

When was your pet exposed to new/unvaccinated pets?(Required)

Is your pet up to date on vaccines?(Required)

Yes

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Coughing – End

Sneezing(Required)

Yes

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Sneezing – Additional Details

How long has your pet been sneezing?(Required)

Does your pet have any known allergies?(Required)

Yes

What time of the day are symptoms most severe? (ex. First thing in the morning when trying to get up after sleeping all night; with exercise; no specific reasoning for symptoms occurring; or all the time?)(Required)

Is there any known trauma?(Required)

Yes

Explain what happened and when the trauma occurred(Required)

When did the difficulty moving/getting up/lameness first occur?(Required)

Is your pet on any medications for arthritis?(Required)

Yes

What is being given and when was the last dose?(Required)

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Difficulty Moving/Getting Up/Lameness – End

Pain(Required)

Yes

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Pain

Please explain in detail the area(s) your pet is experiencing pain.(Required)

Is there any known trauma or past injuries that could be contributing to the pain?(Required)

Yes

Please explain:(Required)

When did your pet first start experiencing pain?(Required)

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Pain – End

Other(Required)

Yes

Hidden

Others

Please explain in detail what symptoms your pet is experiencing.(Required)

Please explain when these symptoms first started.(Required)

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Others – End

Reason for Visit (must select at least one option):(Required)

Yearly Wellness *(Included: comprehensive exam, vaccinations, fecal exam, heartworm test)

Illness *(please note that most illnesses will require further diagnostics beyond an exam for the best medical care)

Injury (please note that most injuries will require further diagnostics beyond an exam for the best medical care)

Recheck

Other

Other Reason

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Yearly Wellness

Please choose one of the following:(Required)

My pet is due for yearly vaccines or boosters

My pet has never had vaccines before, and I would like to get them up to date

Please include previous vaccine records if they were not done at our hospital.(Required)

Unable to provide

Already provided to front desk staff

Emailed to: [email protected]

Please choose one of the following regarding recommended yearly bloodwork for your pet: (this bloodwork provides much more information than just heartworm test results and can give your young pet a baseline to refer to as they grow older or monitor the internal function of your senior pet).(Required)

I would like my pet to have junior/senior bloodwork done today

I decline the recommended yearly junior/senior bloodwork to be done today

What are we rechecking?(Required)

Do you feel your pet has improved or declined since last visit? Please explain.(Required)

Is your pet on any medication(s) for this condition?(Required)

Yes

If yes, please list name of medications and last dose given.(Required)

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Recheck – End

Additional Services Requested (please check all that apply):(Required)

Anal Gland Expression

Bath

Nutritional counseling/weight management

Clean Ears

Microchipping

Nail Trim

None

Please provide additional details regarding your pet, if necessary.

Is your pet currently on heartworm prevention?(Required)

Yes

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Heartworm Prevention

What preventative is your pet on?(Required)

I’m not sure, but it was last dispensed to me from this hospital.

Other

Please explain:(Required)

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Preventation – Addtional Details

Are refills needed?(Required)

Yes

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Refills – Yes

Quantity needed:(Required)

6 Months

12 Months

Other

Other Quantity(Required)

Select all that apply:(Required)

My pets medications have been dispensed to me from this hospital within the past 6 months.

My pets medications have been dispensed to me from another hospital.

My pet is currently getting over-the-counter medications.

Please list all medications – including frequency, dose and hospital where records can be obtained.(Required)

Please list all over the counter medications – including frequency, dose and reason for taking.(Required)

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Any medications

Has your pet ever had an adverse reaction to any medications, vaccines, or procedures?(Required)

Yes

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Adverse Reaction

Please explain by providing as many details as possible:(Required)

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Adverse Reaction

Budget and Treatment Consent:

For patients that are being evaluated the doctor will perform a comprehensive exam starting at $70.75. Should any tests or treatments be necessary in addition to the exam, please call me if the total costs exceed:(Required)

$300

$500

$700

By selecting this option, I am stating that I do NOT have a budget for my pet’s visit, and I give consent for the veterinarians at Animal Care Center and Pet Care Center to treat my pet as needed and I agree to assume all financial responsibility regardless of the total amount charged to my account.

Other

Please enter other cost(Required)

Acknowledgment:

I acknowledge that I am the owner/appointed caregiver of . By providing a specific budget for veterinary services, I acknowledge and agree to the following terms:

Approval of Treatments:

Recommendation for Itemized Plan:

Financial Responsibility:

By signing below, I, the owner/appointed caregiver of affirms their understanding and acceptance of these terms and selections.

Signature

Date

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

Drop Off Agreement