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Owner Phone Number (required)
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Primary Contact Name and Phone Number on appointment day (if different from Owner Name) (required)
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Pet's Name (required)
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Reason for Visit - My pet is here today for (required)
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Overall well-being, weight, appetite, thirst, and eliminations (required)
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If Abnormal, explain
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Daily diet (brand + dry or canned), frequency of feeding, and when your pet last ate (required)
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List medications you are currently administering to your pet, including heartworm prevention, flea control, supplements, and when dose(s) were last given (required)
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I need the following medication(s) refilled (required)
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-> **FOR ILLNESS VISITS or FOLLOW-UP ONLY: Please explain the problem *and* how long it has been going on (and if the patient is doing better, worse or the same)
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For vaccine appointments: Has your pet had prior reactions to the requested vaccines or treatments?
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Cats Only -- My cat primarily lives
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Day Patient ("Drop Off") Information |
If you require an estimate, please discuss this with a service representative or nurse *before* dropping off your pet. |
Day patient discharge times are typically between 4 and 6 p.m. Please do not pick up your pet until a doctor or nurse has communicated with you that your pet is ready. We are unable to guarantee a specific discharge time due to the veterinary team's surgery, inpatient, and urgent patient priorities. Thank you for your understanding. |
**Day patients are evaluated (triaged) based on severity/complexity of the problem, then by order of arrival. Critical and anesthetic/surgery patients receive priority attention. Thank you for understanding. ** |
CPR Authorization: In the unlikely event that complications develop and your pet’s breathing and/or heart stop while in our care, do you want us to perform CPR (resuscitation)? |
(required)
(** Please understand that in the event your pet requires CPR, additional charges will incur for treatments utilized during CPR.)
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Client/Authorized Signature (Please type your first and last name) (required)
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