Drop-Off Form

Please complete this form before your next visit.

Save time during your next visit by completing your drop-off form online before your appointment. We look forward to seeing you soon!

1. Owner's name and information:

Your Name and Last Name: *

First

Last

Best contact phone for the day: *

Can this number receive texts? *

Email *

Pet's name: *

2. Please describe what patient is presenting for:

What is your concern today? *

How long has it been going? *

Has it gotten better or worse? *

Have you attempted to medicate your pet for this/these issues? Yes or no. If yes, with what? *

Do they have a history of same symtoms or condotions? *

If yes to above question, how long ago?

Is patient coughing or hacking? If yes, is this new? How often? *

Please describe your pet's diet including any recent changes or addition.

Is your pet vomiting? *

If they are vomiting how often?

What was the last time they vomited and what did they vomit?

Is your pet having diarrhea? *

If yes, is there blood in stool?

Is there an increased in frequency of defecation?

7. Heartworm and flea prevention:

What flea prevention is your pet on? *

When was their last dose of flea prevention? *

What heartworm prevention is your pet on? *

When was their last dose of heartworm prevention? *

Is the pet on any supplements? If yes, please list them all including herbal medications. *

Any new changes in environment? (recently moved, changes in schedule, new pets in house, recent guests, etc.) *

10.

There is no set pick up time for drop-off appointments. Please plan for pick up at 5pm on regular working days or 12pm on Thursdays. If we are done sooner, we will call you to pick up at an earlier time. If your pet is not picked up by closing time an additional fee for late pick up or boarding will be added to your account. *

I understand
I decline (Drop off will be canceled)

Authorization to treat: I here by authorize the attending veterinarian to examine and treat my pet. I accept full responsibility for ALL FEES AND CHARGES incurred in the work up and treatment of my pet. I understand there may be unforeseen complications with treatments. Quail Meadow Animal Hospital's vet and staff will do their best to diagnose and successfully treat my pet but I understand that not one single test may/will be able to diagnose my pet, as well as that the success of treatment cannot be guaranteed. *

I understand
I decline (Drop-off will be canceled)

12.

Fees: You will receive a basic treatment plan at the time of drop off and a deposit will be required at that time. Once our veterinarian performs their exam further work up or medications may be required. *

I agree
I disagree (Drop off will be cancelled)

e-Signature *

Clear Signature

This is your pet that you are dropping off at our hospital and you have full custody and decision making power over the pet. You are 18 years and older. You consent to diagnostics and treatments. You understand treatment and diagnostics are not a guarantee of success. You understand there may be unforeseen complications with your pet treatments. You agree to pick up your pet prior to closing and you consent to Quail Meadow Animal Hospital treating your pet. By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.

Drop-Off Form

Please complete this form before your next visit.

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