Please complete the following Drop-Off Form prior to dropping your pet off for an exam with the Doctor. 1 Start 2 Complete Basic Information Your Name (Last, First) * Pet's Name * Date of Drop-Off Appointment * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20162017201820192020 Do you consider your pet's condition to be critical? * - Select -YesNo Background Length of present condition? * Briefly describe the problem: * What diet do you feed your pet? (include treats) * Is your pet's appetite normal? * - Select -YesNo Are your pet's vaccines current? * - Select -YesNo If no, list those due Is your pet currently on any medications? * - Select -YesNo If yes, what medications (include: dose, frequency and any over the counter medications and supplements) Is your pet allergic to any medications? * - Select -YesNo If yes, what medications is your pet allergic to? Is your pet on Flea Preventative? * - Select -YesNo If yes, what flea prevenatitve and when was it last given? Is your pet on Heartworm Preventative? * - Select -YesNo If yes, what heartworm medication and when was it last given? Are there any other pets in the household? * - Select -YesNo If yes, please list: Does your pet do any of the following? Coughing * - Select -YesNo If yes, how often does your pet cough? Sneezing * - Select -YesNo If yes, how often does your pet sneeze? Vomiting * - Select -YesNo If yes, how often does your pet vomit? Diarrhea * - Select -YesNo If yes, how often does your pet have diarrhea? Dark, sticky stool * - Select -YesNo If yes, how often does your pet have dark, sticky stool? Drinking more than usual * - Select -YesNo If yes, how often and how much? Lethargic * - Select -YesNo If lethargic, please describe Frequent/Excessive Urination * - Select -YesNo If yes, how often is your pet urinating? Cats Please select the option that best describes your cat: - None -Indoor OnlyIndoor/OutdoorOutdoor Only Dogs Do you go to the dog park? - None -YesNo 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? - None -YesNo 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? - None -YesNo 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? * - Select -YesNo If yes, where? (City and State) Do you have Pet Insurance? * - Select -YesNo 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? * - Select -YesNo 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.
