Canine 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?
    How much time does your pet spend outside?
    Current Heartworm prevention:
    Last dose given?
    Current Flea/Tick prevention:
    Last dose given?
    What

    medications
    or

    supplements
    does your pet receive?
    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 activity level or have you noticed any mobility issues?
    If yes, what change(s) have you noted and when did you first notice?
    Any change in your pet's

    urination
    or

    defecation
    ?
    If yes, what change have you noted and when did you first notice?
    Have you noticed any

    Coughing, Sneezing, Vomiting or Diarrhea?
    If yes, please explain and note when you first observed symptoms:
    Do you have any skin concerns?

    Lumps
    or

    Bumps
    noted?

    Redness
    or

    Itching?
    If yes, please describe location and how long it has been present:
    Has your pet shown any previous fear/anxiety/stress at the veterinarian?
    If yes, please explain
    How often is your pet boarded or in doggy day care?
    Does your pet travel hike or camp?
    If yes, how often?
    Does your pet have regular playtime with family members?
    How long each day?
    How much time does your pet spend alone each day?
    Do you use puzzle toys for enrichment?
    Does your pet receive regular exercise?
    How often?
    Does your pet receive any

    dental care
    at home? (teeth brushing, dental treats, water additives, etc).
    If yes, how often?
    Is your pet sensitive or allergic to any medications/food/vaccines?
    If yes, please explain
    Do you have any behavioral concerns?
    If yes, please explain

     

    Please indicate whether you would like us to:
    Call you when examination is complete for a treatment estimate -OR-Treat as necessary up to $

    Please read and check EACH option below (mandatory):

    Please note, we will strive to keep charges in line with any treatment plan given, however, unforeseen situations may arise at which time we will inform you of additional costs. If we cannot reach you, and aprocedure 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, physical exams and free of internal and 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 5:00pm (11:00am on Saturday) to avoid a late discharge fee.


    Emergency Services


    Please choose ONE of the following options:

    In the event that my pet undergoes cardiac or respiratory arrest while boarding at Fullwood Animal Hospital, I authorize the following CPR code:

    CPR: involving intubation, IV catheter placement, chest compressions, oxygen therapy and medications such as epinephrine, atropine, etc

    DNR: No resuscitation


    Social Media Release (optional):

    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.