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:
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:
Current Heartworm prevention:
Last dose given?
Current Flea/Tick prevention:
Last dose given?
What medications or supplements does your pet receive?
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
How often is your pet boarded or in doggy day care?
Has your pet shown any previous fear/anxiety/stress at the veterinarian?
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 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.

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.