Animal Drop Off Form
DROP OFF • SURGICAL CONSENT • DENTAL FORM • PRESCRIPTION REFILL

ONLINE DROP OFF MEDICAL EXAM FORM

You may also dowload the form here and bring it with you.

Client and Patient Information:
Your Name: Your Pet's Name:
Phone: Alternate Phone:
Best Time to Call:
 
What problem is your pet presenting with?
 
When did you first notice the problem?
 
Has the problem changed since you noticed it? Yes No
If yes, how?
 
Has your pet had this problem before? Yes No
If yes, when?
 
Is your pet eating? Yes No Don't Know
Is your pet drinking? Yes No Don't Know
 
If there is anything else you would like the doctor to know, please describe below:
 
What Medications, Vitamins, or Nutritional Supplements Has Your Pet Received Recently?
Please list the names & dosages of all drugs or nutritional supplements your pet currently takes & day of last dose.
Current Medication Description #1
Name of Medication
Dosage Taken Date of Last Dose
Current Medication Description #2
Name of Medication
Dosage Taken Date of Last Dose
Current Medication Description #3
Name of Medication
Dosage Taken Date of Last Dose
Current Medication Description #4
Name of Medication
Dosage Taken Date of Last Dose
 
Is your pet allergic to any medications or had a reaction to any? Yes No
If Yes, explain below:
 


Best Friends Animal Hospital does not charge for keeping your pet for outpatient services.  If more intensive care is required, hospitalization charges could apply.  You would be contacted for authorization before any such treatment was initiated.  To diagnose your pet our doctors may only need an examination, or we may need additional tests.  In an effort to diagnose your pet’s condition as quickly as possible, please select from the level of initial diagnostics you will consent to without prior contact and specific authorization.

Please indicate the phrase that expresses your wishes:

Up to $50 Up to $100 Up to $200 Call for approval before anything is done

 

We will only use this authorization to perform non-invasive, in-hospital tests.  Your choice will in no way alter the recommendation or treatment your pet receives.  The doctor will contact you before any treatment is done that exceeds your approval above.

Consent for Exam, Treatment, and/or Surgery:
I am the owner, or a representative of the owner, of the animal(s) presented & have the authority to execute this consent.  I authorize & direct the veterinarians of Best Friends Animal Hospital (& their designated assistants) to administer authorized treatment as needed on the basis of findings during the course of evaluation:  to diagnose, prescribe, sedate, anesthetize, perform therapeutic procedures &/or surgery as their judgment may dictate to be advisable for the patient’s well being.  I understand I will be advised as to the nature of the procedures & the risks involved.  I understand that no warranty or guarantee will be made as to the results or cure.  An estimate of these fees will be provided at my request for the initial assessment & treatment for the patient(s) presented.  I realize that actual expenses may differ from the estimate dependent on the patient’s condition & length of stay in the hospital.  Best Friends will try to contact me if emergency treatment is required.  I also understand & will be responsible for expenses incurred in an emergency when I cannot be reached or there is no time to contact me.  I will be fully responsible for monitoring the ongoing expenses & will be fully responsible for all expenses incurred through the animal’s diagnosis & treatment. 

~ All fees are to be paid in full upon completion of the visit. ~
~ A deposit is required if the patient is being hospitalized. ~
 
By initialing here I acknowledge that I am the owner, or legal representative of the owner, of the pet described, all information I have provided is true to the best of my knowledge, and that I agree to the terms outlined in this form.