Drop-off Form

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Drop-off Formorangevetadmin2022-09-28T06:08:38-07:00

Drop-off Form

Thank you for selecting our hospital for your pet’s care. In order to facilitate the admission process, please complete this document and sign it electronically prior to leaving your pet with us.

Step 1 of 3

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Have you been to our hospital in the past two years?(Required)

Yes

Email(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Cell or Home Phone(Required)

Pet's name(Required)

Pet's sex(Required)

Male

Female

Is your pet altered?(Required)

Yes

Breed

Age range of your pet:(Required)

One year or younger

Older than one year

Pet's age in months

Pet's age in years

Phone number where you can be reached while your pet is here(Required)

Time of the last meal your pet ate(Required)

Does your pet have any medical problems?(Required)

Yes

If yes, please describe

In the last 48 hours has your pet experienced any of the following? Please check all that apply(Required)

Vomiting

Coughing

Lethargy

Abnormal stool

Sneezing

If you checked one of the boxes above, please describe the condition here:

Please list any medications your pet is currently taking AND when the last dose was given. If "none", so state.(Required)

Do you need any of the following? Check any box that applies. (All services will be done at the discretion of the doctor)

Toe nail trim

Anal gland expression

Heartworm test

Heartworm prevention refill

Flea prevention refill

Vaccines

Microchip

Miscellaneous refill

Other

A flea preventative will be administered if fleas are found on your pet today – There will be an additional fee. Please ask for a quote

Payment is due the day of services. The hospital does not provide financing.

Additional information(Required)

A flea preventative will be administered if fleas are found on your pet today – There will be an additional fee. Please ask for a quote

I have read this and understand it.

Signature(Required)

Today's date(Required)

MM slash DD slash YYYY