Drop Off Form

Your Name:                Today’s Date:

Your Pet’s Name:    Why he/she is here:

We have arranged for you to leave your pet here today to allow our doctors to examine your pet as soon as possible today.  Please read through the following questions, and answer any that may apply to your pet today.  Please read and sign the authorization on at the bottom of this form.

Everything was okay with my pet until

Since then:

 MY PET IS LETHARGIC 

APPETITE                NORMAL                   POOR                        EXCESSIVE

WHEN DID YOUR PET EAT LAST? 

WATER INTAKE     NORMAL                   POOR                        EXCESSIVE

URINATION              NORMAL                   STRAINING              MORE FREQUENT

STOOL                      NORMAL                   WATERY/SOFT       CONSTIPATED    DIARRHEA

ANY GARBAGE/PLANT EXPOSURE?  Yes  No

VOMITING?                 None       Yes     WHAT COLOR

RECENT DIET CHANGE?  Yes  No

SKIN:                          NORMAL       ITCHY HOT SPOTS            LUMPS/WARTS

EARS:                         NORMAL                   SMELLY                    HAIRY

SEIZURE:                   NO HISTORY           FIRST TIME              EPILEPTIC

Please describe in your own words what seems to be the problem

and indicate the body part that you think is the problem.

PLEASE LIST ANY ADDITIONAL PROBLEMS:

LIST ALL MEDICATIONS OR SUPPLEMENTS YOUR PET IS RECEIVING AND IN WHAT DOSAGE:

Phone:           Alternate Phone:

By clicking the "SUBMIT" button, you agree to all of the terms and conditions as stated on this form.