Drop-Off Form

Please complete the following Drop-Off Form prior to dropping your pet off for an exam with the Doctor.

Basic Information

Your Name (Last, First) *

Pet's Name *

Date of Drop-Off Appointment *

Month

Day

Year

Do you consider your pet's condition to be critical? *

Background

Length of present condition? *

Briefly describe the problem: *

What diet do you feed your pet? (include treats) *

Is your pet's appetite normal? *

Are your pet's vaccines current? *

If no, list those due

Is your pet currently on any medications? *

If yes, what medications (include: dose, frequency and any over the counter medications and supplements)

Is your pet allergic to any medications? *

If yes, what medications is your pet allergic to?

Is your pet on Flea Preventative? *

If yes, what flea prevenatitve and when was it last given?

Is your pet on Heartworm Preventative? *

If yes, what heartworm medication and when was it last given?

Are there any other pets in the household? *

If yes, please list:

Does your pet do any of the following?

Coughing *

If yes, how often does your pet cough?

Sneezing *

If yes, how often does your pet sneeze?

Vomiting *

If yes, how often does your pet vomit?

Diarrhea *

If yes, how often does your pet have diarrhea?

Dark, sticky stool *

If yes, how often does your pet have dark, sticky stool?

Drinking more than usual *

If yes, how often and how much?

Lethargic *

If lethargic, please describe

Frequent/Excessive Urination *

If yes, how often is your pet urinating?

Cats

Please select the option that best describes your cat:

Dogs

Do you go to the dog park?

If yes, how often do you go to the dog park and when was the last time you were there?

Do you go to the dog beach?

If yes, how often do you go to the dog beach and when was the last time you were there?

Does your dog go to doggy daycare?

If yes, how often does your dog go to doggy daycare and when was the last time they were there?

Additional Information

Do you travel outside "Orange County" with your pet? *

If yes, where? (City and State)

Do you have Pet Insurance? *

If yes, which Pet Insurance and do we have a copy of your claim form to submit?

Phone number where you can be reached the day of your pet's appointment *

Best time to reach you the day of your pet's appointment? *

Will Someone, Other Than Yourself, Be Picking Your Pet Up? *

If yes, what is their name and phone number?

By submitting this form, I understand and agree to the following:

Following the physical examination, we will telephone you regarding your pet's condition and our recommendations for diagnostics and treatment.
It is your responisibility to request an estimate for the cost of diagnostics and treatment.
If someone other than yourself is to pick-up your pet, payment is expected, in-full at the time of drop-off or pick-up.
No major treatment or surgeries will be performed without your consent unless the doctor considers the condition to be life theatening.
At the doctor's discretion, vaccines will be given if the pet's vaccination status is not current.
A fee will be assesed for today's examination, treatment, and kennel occupancy.
Animals will be discharged only during regular hospital hours.

Drop-Off Form

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