Drop-off/Patient Medical History Form
Sign in to Google to save your progress. Learn more
Owner Contact Information
Date of Service *
MM
/
DD
/
YYYY
Reason for Today's Visit including any questions or concerns: *
Owner's Name *
Animal(s) Name *
Provide all phone numbers where we can contact you today *
Patient Information
Species *
Your pet is *
Approximate age or date of birth *
Breed *
Color *
Medical History
Is your pet on monthly heartworm prevention? *
Last date given?
MM
/
DD
/
YYYY
Name of heartworm prevention
Is your pet on flea and/or tick prevention? *
Last date given
MM
/
DD
/
YYYY
Name of flea/tick prevention
Does your pet have any known allergies to food, medications, or vaccines *
If yes, please list known allergies
If your pet had a reaction to a vaccine, please list approximate date of last known vaccine reaction
Please list all medications your pet is currently taking, including over the counter medications, nutritional supplements, along with prescribed medications(include dose and how often it is given) *
What is your pet's normal diet? *
How much are they fed per day? *
Has your pet had any of the following in the past week?
*
Required
If you answered yes to any of the above, please provide the duration
When did your pet last eat or drink? *
MM
/
DD
/
YYYY
Drop Off Policies for KAC LLC

All day boarding, boarding, and grooming animals are required to be up to date on vaccinations and free of parasites, fleas, and ticks. If your pet is not up to date on vaccinations and/or parasites, fleas, or ticks are detected on your pet, a physical examination, appropriate treatment, and/or vaccinations, will be given to your pet(s) and charged to your account.

Required canine vaccinations for boarding, day boarding, and grooming include Rabies, Distemper, Parvovirus, Adenovirus (DA2PP), Bordetella (kennel cough), and Canine Influenza H3N2/H3N8 (pending availability of the canine influenza vaccine at the time of boarding or grooming appointment). Required feline vaccinations include Rabies and Feline Distemper (FVRCP). If your pet has been exposed to infectious respiratory diseases such as kennel cough or canine influenza, or if your pet is showing symptoms of respiratory illness such as cough or fever, within 14 days of scheduled drop off date, we will be unable to board or groom your pet.

Examination by a veterinarian is required if your dog or cat needs to be vaccinated and/or if your pet is sick at the time of arrival. Fecal floatation will be performed if your pet has not been screened for internal parasites within 12 months prior to arrival date. Fecal floatation will be required if your pet is not currently receiving monthly internal parasite prevention. If your pet is displaying symptoms or is suspected of having an infectious disease, which could be transmissible to other animals in our clinic, arrangements to have your pet discharged or transferred to a referral facility may be required. 

Clients must complete the required forms prior to or at the time of arrival. Forms must be completed by the owner with instructions including, but not limited to, medications, feeding instructions, belongings, and grooming or veterinary appointment requests. If the forms are not completed, KAC, LLC cannot be responsible for giving or dispensing medication, feeding instructions, belongings, or appointment requests. Clients are required to leave a valid phone number(s) and email address where we can reach you during normal business hours in the event of an emergency or question regarding your animal.

All medications brought with your pet must be appropriately labeled in the original prescription pill vial as prescribed by a veterinarian or pharmacy. Medications not brought in the original prescription pill vial cannot be administered to your pet while boarding or day boarding with us.

We encourage you to bring your pet’s normal diet food for the entire length of the boarding stay. If you elect to not bring your pet’s food, or if the amount of food is not sufficient for the length of boarding stay, a $3.00 per day in house food fee will be charged to your account. Please do not bring your pet’s bedding and toys from home for the boarding stay as we cannot guarantee the return of these items at the conclusion of your pet’s boarding stay.

We require a 24-hour cancellation notice for grooming and boarding appointments. The boarding cancellation fee is calculated as 50% of your original scheduled boarding reservation. The cancellation fee for grooming is $20.00. Cancellation fees will be collected at the time of cancellation.

We kindly ask you to drop off and pick up boarding and grooming patients by no later than Monday – Friday by 5:30pm and by 11:30 am on Saturday. If your plans change and are unable to pick up on the day of scheduled departure, please notify us immediately. For the safety of our staff and security purposes, KAC, LLC does not allow after-hours, holiday, or Sunday pick-up for boarding patients.

KAC LLC Release for Treatment
Release for treatment: I the undersigned do certify that I am the owner, or authorized agent of the owner of this animal(s); that I hereby authorize Knoxville Animal Clinic, LLC, their agents and representatives, to perform medical or surgical procedures, physical examinations, anesthesia, x-ray, administer drugs, or other such treatment(s) as the veterinarian deems necessary while day boarding, boarding, and grooming patients. I agree to accept responsibility for the payment of all services rendered.

All day boarding, boarding, and grooming animals are required to be up to date on vaccinations, free of parasites, fleas, and ticks. If your pet is not up to date on vaccinations and/or parasites, fleas, or ticks are detected on your pet, a physical examination, appropriate treatment, and/or vaccinations, will be given to your pet(s) and charged to your account. I authorize Knoxville Animal Clinic, LLC to release any and all of my pet’s medical records in good faith without additional consent.

In the event this account is referred to an outside agency, credit reporting bureau, or attorney for collection, I agree to pay all attorney fees, collection costs, court costs, and/or any other expenses incurred during collection. I hereby state that I have read this release, that I understand the agreement and that I may request a copy of this agreement. I have read and understand all KAC, LLC policies and agree to terms as described above for boarding, day boarding, grooming and drop off patients.
Have you read and understand our policies and release for treatment? *
Your typed name below constitutes your consent to our policies and your authorization of the Release for Treatment *
Today's Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Knoxville Animal Clinic. Report Abuse