TEMP Patient Drop-Off Form URLThis field is for validation purposes and should be left unchanged.Date MM slash DD slash YYYY Owner's Name:(Required)Pet's name:(Required)Person dropping patient off (if different from owner):Email:(Required) Phone:(Required)Phone number where you can be reached today.Alternative phone number(s):Reason for visit:(Required)Did you bring any samples (i.e. urine, feces)?Please complete if your pet is here for illness:Appetite Decreased Normal Increased Weight Loss Normal Gain Water consumption Decreased Normal Increased Urination Decreased Normal Increased Bowel movements Constipated Normal Diarrhea Vomiting No Yes Activity level Decreased Normal Increased Lameness No Yes If yes, which leg?Is your pet on any medications? Prescriptions? Supplements? Over-the-counter?(Required)Anything else we should know about your pet today?Some pets require sedation for adequate physical examination or treatment. May we sedate your pet if necessary?(Required) No Yes Call first The veterinarian may recommend x-rays, bloodwork, fecal, or urinalysis to aid in diagnosis. May we perform these procedures on your pet today?(Required) No Yes Call first The veterinarian may recommend treatments such as subcutaneous fluids or injectable medications. May we perform these treatments on your pet today?(Required) No Yes Call first Owner release:(Required) I agree to the following:I understand that all reasonable precaution will be used against injury, escape, or death of my pet. The clinic and staff will not be held liable for any problems that develop provided reasonable care and precautions are followed. I understand that any problems that develop with my pet while I am absent and, if I cannot be reached by telephone, will be treated as deemed best by the veterinary team and I will assume full responsibility for the treatment expense involved. I acknowledge this is a drop-off appointment and I may not have face-time or talk with the veterinarian caring for my pet. Communication concerning my pet may be via a receptionist, veterinary assistant, or licensed veterinary technician.Maximum amount not to exceed: $Owner/Agent:Please type your full name as signature.Date MM slash DD slash YYYY
