Drop Off Form Same Day Procedures Owner Full Name*Pet Name*Primary Contact #*This is my...*CellWorkHomeSecondary Contact #This is my...CellWorkHomeWhat diet (brand/formula) is your pet on at home?*How much do you feed?*How often do you feed?*Lifestyle*Indoor solitaryIndoor socialIndoor/OutdoorStrictly OutdoorIs your pet current on Heartworm Prevention (what medication)?*Does your pet have any allergies to food or medications? Please list YES or NO and if YES please list details*Please list any medications (if any)your pet has received in the last 24 hours?Medication 1 (name, dose, time given)Medication 2 (name, dose, time given)Medication 3 (name, dose, time given)Medication 4 (name, dose, time given)Please describe the problem(s) your pet is having, pertinent history leading up to the current condition, any previous major medical problems, and/or what procedures you would like us to do:*IF FLEAS OR TICKS ARE FOUD ON YOUR PET AT THE TIME OF ENTRY, YOUR PET WILL BE TREATED AND THE MEDICATION WILL BE REFLECTED ON YOUR INVOICE UPON CHECK-OUT.Acknowledgement of flea/tick statement* YES - I UNDERSTANDRabies VaccineDistemper/Parvo VaccineLeptospirosis VaccineBordetella (Kennel Cough)CIV (Canine Influenza)Rattlesnake VaccineLyme VaccineFecal (intestinal parasite test)Heartworm Test (recommended by DVM annually and required to get a refill on prevention)Pro Heart (initials)Acknowledgement of exam statement* YES - I UNDERSTANDIn admitting my pet for diagnostics and treatment, I authorize the veterinarians of Babcock Hills Veterinary Hospital, and their support staff, to administer such treatment and/or perform such diagnostic procedures as deemed necessary. I have read this authorizationDigital Signature:*Date* NameThis field is for validation purposes and should be left unchanged.