Drop Off Form Drop Off Form Clients Name First Last Patients NameDate Date Format: MM slash DD slash YYYY Why is your pet here today?When did the problem startPlease list any medications/supplements that your pet is taking and when last dose was given.Please check any of the appropriate symptoms: Eating notmally Not eating Eating ravenously Weight loss Weight gain Behavior changes (describe below) Lethargic/less active Itching & scratching Hair loss Gagging Vomiting Diarrhea with blood BM straining Scooting Straining to urinate Urinating more frequently Urinating blood Leaking urine / spotting Coughing Panting excessively Difficulty breathing Nasal discharge Eye discharge Eye redness / color change Shaking head Scratching at ears New swelling / mass(es) (describe below) Any other information that can assist us?Current dietIs your pet on heartworm prevention? YES NO Doing initial testing can save time diagnosing your pet. Initial basic test could include blood testing, fecal tests, skin scrapings, needle aspirates, x-rays, and ear swab examination. Please contact me first if the cost of any tests plus the office visit of $58 will exceed the following: $75 $125 $200 $300 Contact me first before any tests are run Bloodwork YES NO X-Rays YES NO I am the over (or agent of the owner) of the animal described above. I authorize the doctor(s) of Lake Palestine Animal Hospital to provide veterinary services as requested or in emergency circumstances to follow through with such procedures as are necessary for the well being of my pet. I accept full responsibility for the fees generated by such services, and I realize that they are due and payable at the time the services are rendered and at the time that my pet(s) is released from the hospital. Any exceptions to the policy must be authorized PRIOR to the performance of any serviceOwner's / Agent's SignatureDate Date Format: MM slash DD slash YYYY Best phone number(s) where you can be reached todayPhone
