animalmedser / Pet Drop Off Form

We are happy to offer our busy clients a pet drop off service. Pets can be dropped off at the office for routine procedures as well as sick animal situations* from 7 a.m. to noon Monday, Tuesday, Thursday and Fridays. To accomplish the most out of such a service, we must have information on what problem (s) exist in your pet and what you would like for us to do. Please copy this form and fill it out. Bring it with you when you drop off your pet.

* PLEASE NOTE that we cannot take dogs with respiratory or gastrointestinal symptoms that could be contagious diseases. Owners of pets with such problems are urged to call the office before bringing in the pet.

PET DROP OFF INFORMATION

Client Name ___________________________________

Telephone number to reach you today ____________________________

E-mail contact information (if applicable) __________________________________________

Pet's Name ___________________________ Breed ____________________________

Has your pet been seen by us before? (    ) yes (    ) no (If not, please fill out a New Client or New Pet Form from the Forms Page. *

When was your pet's last meal? _____________ What did he/she eat? ______________________

          __________________________________________________________________________.

What medication (s) , if any, has your pet received in the last 24 hours?

     Name of Medication                                 Amount Given                        What time was it given?

___________________________         ___________________          __________________________

___________________________         ___________________          __________________________

___________________________         ___________________          __________________________

Is your pet sensitive or allergic to any medicaiton or food? (       ) yes    (     )   no.

If so, please list here:______________________________________________________________

________________________________________________________________________________

What vaccinations, if needed, would you like for us to administer today?

  (       ) Rabies                  (       )   DHLPP(canine) (       ) Bordetella (canine)
(       ) FVRCP (feline)     (       )   Feline Leukemia.

Please describe the problem (s) your pet is having, pertinent history leading up to the condition, how long the pet has been experiencing the problem (s), any previous therapy for this or any other problems in the last 6 months, any ongoing medical issues, and what you would like for us to do:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________
Use the back of this page if you need more space.

Would you like us to:
   (       ) treat your pet after the examination?
   (      )   call or email you with the findings of the exam and an estimate of treatment cost prior to trating your pet?

* Please note that if we have not seen your pet before, we will need to be able to contact you regarding your pet's examination prior to instigating any treatments. This contact can be by phone or email.

PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE WITH
DR. BUTLER OR TAMARA BUTLER, THE OFFICE MANAGER.

In admitting my pet (s) for diagnostics, treatment, or surgery, I authorize Dr. Butler or Animal Medical Srervices P.C. and the support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.

Signed __________________________________________________________

Date _____________________________

Animal Medical Services P.C.   Form revised August 20, 2009