Illness Drop-Off Form

Phone number where you can be reached today:*

Today's Date:

Name of Pet:

Pet Species:

Feline

Canine

Is your pet:

Male

Female

Male/Neutered

Female/Spayed

Pet's Age:

Does your pet have any history of vaccine reactions?

yes

no

If yes, please explain:

Does your pet have any known allergies to food, medications, or anesthetic agents?

yes

no

If yes, please explain:

When did your pet last eat?

Reason For Drop Off:

Vomiting? How long?

Gagging? How long?

Sneezing? How long?

Diarrhea? How long?

Scratching? How long and where?

Appetite loss? How long?

Shaking head? How long?

Weakness/Lethargy? How long?

Scooting? How long?

Limping? How long and which area?

Increased Thirst and/or Urination? How long?

Coughing? How long?

Is your pet up to date on their vaccinations?

yes

no

Is your pet up to date on their heartworm and flea prevention?

yes

no

Is your pet up to date on their heartworm and flea prevention?

yes

no

Some procedures may require sedation or anesthesia.

I acknowledge receipt of an estimated medical treatment plan and agree to the sum.***

yes

no

Illness Drop-Off Form

Phone number where you can be reached today:*

Today's Date:

Name of Pet:

Pet Species:

Is your pet:

Pet's Age:

Does your pet have any history of vaccine reactions?

If yes, please explain:

Does your pet have any known allergies to food, medications, or anesthetic agents?

If yes, please explain:

When did your pet last eat?

Reason For Drop Off:

Vomiting? How long?

Gagging? How long?

Sneezing? How long?

Diarrhea? How long?

Scratching? How long and where?

Appetite loss? How long?

Shaking head? How long?

Weakness/Lethargy? How long?

Scooting? How long?

Limping? How long and which area?

Increased Thirst and/or Urination? How long?

Coughing? How long?

Is your pet up to date on their vaccinations?

Is your pet up to date on their heartworm and flea prevention?

Is your pet up to date on their heartworm and flea prevention?

**Some procedures may require sedation or anesthesia. I acknowledge receipt of an estimated medical treatment plan and agree to the sum.*

Some procedures may require sedation or anesthesia.

I acknowledge receipt of an estimated medical treatment plan and agree to the sum.***