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Drop-off Release Form
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Your Name
Your answer
Phone Number
Your answer
Your Pets Name
Your answer
Reason for Visit
Your answer
What kind of food does your pet eat at home?
Your answer
Have you changed your pet's diet recently?
Your answer
Do you feed your pet table food?
Yes
No
Clear selection
If so, what kind?
Your answer
Is your pet currently of any medication? If so, Please list all
Your answer
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
No
Clear selection
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
No
Clear selection
Do we have permission to x-ray your pet if it is necessary?
Yes
No
Clear selection
Do we have permission to sedate your pet if it is necessary?
Yes
No
Clear selection
If so, when did it eat last?
Your answer
***Please note: Payment is expected at the time services are rendered.***
Digital Signature
Your answer
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