Pet Drop-Off
Information
Client Name:
_________________________________________________
Telephone
Numbers: (please include area code)
Home:(____)_____-_______________
Work:(____)_____-______________
Cell:(____)_____-________________ Pager:(____)_____-_______________
Pet’s Name:
______________________ Breed: ___________________________
Has your pet been
seen by us before?
Yes
No (if not,
please fill out a Client Registration form)
When was your pet’s
last meal? ________ What did he/she eat?
_______________
What medications
(if any) has your pet received in the last 24 hours?
Name of
medication: | Amount given | What time |
| | |
| | |
| | |
Is your pet
sensitive or allergic to any medications or food
no yes
(please
list)_________________________________________________________
What vaccinations,
if needed, would you like us to give your pet today? Please circle:
Rabies
Distemper-Parvo
Feline upper respiratory
Feline Leukemia
Other vaccines:
_____________________________________________________
Tests: Fecal exam Heartworm
Test Blood
Work-Up
Please describe the
problem(s) your pet is having, pertinent history leading up to the
current condition, any previous major medical problems, and what
you would like us to do below:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
If problems arise,
would you like us to:
( ) Contact
you at ( ) work or ( ) home.
( ) Go ahead
with whatever is needed.
( ) Halt
procedure.
*
Please note that if we have not seen your pet before, we will need
to be able to contact you regarding your pet’s examination prior
to initiating any treatments.
PROFESSIONAL FEES ARE TO BE PAID
AT THE TIME SERVICES ARE PERFORMED
How will you be making payment
today? Sorry, we do not
charge!
Cash ____ Check ____ Visa ____ M/C
____ Discover ____ American Ex. ____
* In admitting
my pet(s) for diagnostics, treatment, or surgery, I authorize the
veterinarians of Emerson Animal Hospital, and their support staff,
to administer such treatment and/or perform such diagnostic or
surgical procedures as deemed necessary.
* No guarantee
or assurance can be made as to the results that may be
obtained.
* Further, I
understand that a deposit of 50% is required before services are
performed and I assume full financial responsibility for all
charges incurred by my pet. I realize that these charges may
exceed a given estimate if complications arise. I understand
that I will be contacted prior to treatment, if
possible, should complications occur.
* I
understand that I am personally financially responsible
for all services rendered by the doctors and staff of Emerson
Animal Hospital and that payment is due on the date of the
anesthesia/surgery/dentistry.
Signature:
__________________________ Signature:
_________________________
