Drop Off Consent Form Drop Off Consent FormOwner's NamePet's NameCell Phone NumberHome Phone NumberPreferred Contact Method Cell Phone Number Home Phone Number EmailEmailWhat is the reason for today's appointment for your pet?How long has this problem lasted?If your pet seems painful, what would you rate their pain on a scale of 0 to 10?How has your pet been eating? Normal Increased DecreasedWhat kind of food and how much?How has your pet been drinking? Normal Increased DecreasedHas there been any vomiting? Yes NoHas there been any diarrhea? Yes NoHave you noticed any blood of black, tarry material? Yes NoHow would you characterize your pet’s urination? Normal Increased Decreased Painful Straining Not UrinatingIs your pet on any medication? Yes NoDoes your pet have any chronic health issues? Yes NoHas your pet been exposed to anything abnormal recently? (Garbage, carcass, OTC prescriptions, medications, antifreeze, chocolate, ect.) If yes, what and whenBelongings you are leaving with your petIn the case you cannot be reached, how would you like us to proceed in the case of a life-threatening emergency situation? Please DO NOTHING until I am reached Please PERFORM LIFE-SAVING procedure but nothing else until I am reached Please USE PROFESSIONAL JUDGEMENT and proceed accordinglySignature of Pet Owner Sign Here Signature DateSubmit
