Drop-off Release Form

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Your Name

Phone Number

Your Pets Name

Reason for Visit

What kind of food does your pet eat at home?

Have you changed your pet's diet recently?

Do you feed your pet table food?

Yes

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If so, what kind?

Is your pet currently of any medication? If so, Please list all

Please Check all symptoms your pet has

Vomiting

Sneezing

Diarrhea

Coughing

Anorexia

Lethargy

Water increase

Water decrease

Other:

Is your pet current on all vaccines?

Yes

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For Cats: If not, please mark all vaccines and/or routine tests that are needed today

FeLV, FVRCP

Rabies

Fecal

FeLV/FIV test

For Dogs: If not, please mark all vaccines and/or routine tests that are needed today

DHLPP<CV

Rattlesnake

Rabies

Fecal

Bordetella

Heartworm test

Lyme

Do we have permission to do bloodwork on your pet if it is necessary?

Yes

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Do we have permission to x-ray your pet if it is necessary?

Yes

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Do we have permission to sedate your pet if it is necessary?

Yes

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If so, when did it eat last?

***Please note: Payment is expected at the time services are rendered.***

Digital Signature

Submit

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