Country Club Veterinary Clinic Drop Off Exam Form

Owners Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Pet's Name*
What time would you prefer to pick up?*
Reason for Visit*
Please Check all That Apply
NormalIncreasedDecreased
NormalIncreasedDecreased
LossGainStable
NormalIncreasedDecreased
SoftNormalConstipatedDiarrhea
What is the Appearance?*
PatchyGeneralized
Where?*
NormalIncreasedDecreasedDiscolored UrineIncontinenceStraining
What color?*
SYMPTOMS (Please Check All That Apply)
After SleepingAfter ExercisingClimbing StairsStiffnessScooting on RearShaking HeadBad BreathVomitingCoughingSneezingGaggingListlessSigns of WeaknessLamenessScratchingLumps or BumbsDischargeBehavioral Changes
Additional Comments*
When did you first notice this issue?*
Have you given your pet any medications today (List)?*
When was the last time your pet ate or drank anything?*
**There Will Be An Additional Charge For Sedation, Bloodwork, XRays, And Any Other Test Or Treatment Performed**
By checking this box i agree that i am the owner/agent for described animal, authorize, and request an exam for my pet. I understand that sedation and/or pain medication will be provided if deemed reasonable. I understand the doctor will contact me after she has examined by my pet to discuss recommended diagnostics and treatment, and will have an initial estimate of charges. I can be reached at the provided number on this form. If I cannot be reached at this number, I authorize initial diagnostics, incluiding xrays and blood work if indicated for my pet. Further, if I cannot be reached, I authorize initial treatment, including fluid support and support and other supportive medications be started as indicated for my pet. I authorize anesthesia, surgery and medications if needed for abscess, laceration or other wounds, if my pet is presented for one of these problems (please fill out additional consent forms). I understand, and accept that when anesthesia is involved, there are always inherent risks, including death. I understand payment is due when my pet is discharged, however, a deposit may be required after an estimate is prepared and discussed. I accept full financial responsibility of charges incurred for this pet. I understand that I will be charged for flea medication and a dose will be applied if evidence of fleas is found on my pet today.*
Should be Empty: