Patient drop off and consent form





Your First Name:
Your Last Name:
Your Email (required):
Contact Number (required):
Alternate Number:
Pet Name:
Why are we seeing your pet today?
What food do you feed your pet?
How much do you feed?
Any change in food or water intake?
Any change in your pet’s urination or defecation?
If yes, what change have you noted and when did you first notice?
Any change in your pet’s activity level?
Have you noticed any Coughing, Sneezing, Vomiting or Diarrhea?
If yes, please explain and note when you first observed symptoms:
Any lumps or bumps noted?
If yes, please describe location and how long it has been present:
Is your pet sensitive or allergic to any medications/food/vaccines?
If yes, please explain
Does your pet receive any dental care at home?(brush teeth, Greenies, water additives, etc).
If yes, how often?
What medications or supplements does your pet receive? (including heartworm preventative & flea/ tick prevention):
If presenting for surgery or a dental, was your pet fasted overnight and this morning?

 

Please indicate whether you would like us to:
 Call you when examination is complete for a treatment estimate -OR- Treat as necessary (for dentals, this may include radiographs, extractions, antibiotics, etc.)

 

Please note, we will strive to keep charges in line with any estimate given, however, unforeseen situations may arise at which time we will inform you of additional charges. If we cannot reach you, and a procedure needs to be performed, it will be done and charges will appear on your bill.

All pets admitted to the hospital are required to be current on all vaccinations, parasite checks and physical exams. All admitted pets must be free of external parasites. Animals with fleas or ticks present will be administered a preventative at the owner’s expense.

Pets that are hospitalized on an emergency basis will require a deposit for treatments based on an initial assessment. Extensive hospitalized stays may require keeping charges current prior to expected discharge.

All pets must be discharged by 5:15pm (11am on Saturday) to avoid a late discharge fee.

Procedure(s) to be performed:

 

Medical treatments, including anesthesia, are not without risks. We do all we can to ensure your pet
receives the safest and most up-to-date medical care. However, unforeseen complications do
occasionally arise during or after a procedure. In the event of a complication, the veterinarian will
proceed with treatments deemed necessary in their professional judgment until you can be reached.
Any costs associated with emergency treatments are incurred at the owner’s expense. Your signature
below authorizes the veterinarian to perform the procedures listed above and any emergency
treatments that may become necessary. It also releases Fullwood Animal Hospital of any liability
associated with the treatment of your pet.

Social Media Release:

I agree to allow Fullwood Animal Hospital to use my pet’s name and photographs of my pet and/or myself for any lawful purpose, illustration, advertising, website, Facebook, Twitter, Instagram, YouTube or other media outlet.

Charges for all services must be paid in full at the time of discharge.

Check here to indicate that you agree to the terms of this agreement.

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