Drop Off Form Same Day Procedures Owner Full Name* Pet Name* Primary Contact #* This is my...* Cell Work Home Secondary Contact # This is my... Cell Work Home What 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 UNDERSTAND Rabies Vaccine Distemper/Parvo Vaccine Leptospirosis Vaccine Bordetella (Kennel Cough) CIV (Canine Influenza) Rattlesnake Vaccine Lyme Vaccine Fecal (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 UNDERSTAND In 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 authorization Digital Signature:* Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
