Sick Patient Drop Off

Thank you for entrusting us with the care of your beloved pet. We understand that your pet is a cherished member of your family, and we are committed to providing them with the same love, attention, and expert care that we would give our own.

Please take a moment to complete this form so we can better understand your pet’s needs and ensure the best possible experience. If you have any questions, don’t hesitate to ask—we’re here for both you and your furry (or feathered, or scaly!) friend.

We appreciate the trust you place in us and look forward to caring for your pet!

"*" indicates required fields

Name*

First Last

Email*

Patient Name*

Phone*

Species*

Dog

Cat

Sex*

Male

Neutered Male

Female

Female Spayed

At what number can you be contacted at day of drop off?*

Presenting complaint(s)?*

What abnormal signs is your pet showing or concerns you have noticed?*

How long have you noticed any abnormalities (Please select one)?*

Less than 24 hours

1-2 days

3-5 days

5-7 days

1-2 weeks

1-2 months

Other

Is your pet's appetite?*

Normal

Increased

Decreased

Is your pet's thirst?*

Normal

Increased

Decreased

Are your pet's urinations?*

Normal

Increased

Decreased

Your pet's activity level is?*

Normal

Increased

Decreased

Any vomiting?*

Yes

No

If so, how many times per day?*

For how many days?*

Please describe the contents of the vomitus (clear liquid, digested or undigested food, bile, coffee grounds, foreign/plant material, etc.):*

Any diarrhea?*

Yes

No

If so, how many times per day?*

For how many days?*

Please select each of the following that describes your pet's diarrhea:*

Watery

Semi-formed

Bloody

Mucous

Large Volume

Small Volume

Straining

Normal frequency

Increased frequency

Urgency

Accidents in the house

What diet/type of food is your pet typically fed?*

List anything other than that diet your pet may have eaten or had access to:*

Is your pet coughing?*

Yes

No

If so, how many times per day?*

For how many days?*

Please select each of the following that describes your pet's cough:*

Dry, harsh

Moist

Productive (bringing up phlegm, foam, etc.)

Non-productive

Retching or vomiting at the end of cough

Worse at night

Progressively worsening

Worse after barking, excitement, or exercise

Is your pet limping?*

Yes

No

If so, which limb?*

Is the lameness:

Better

Worse

Same After Exercise

Is your pet itchy?*

Yes

No

If so, what parts of its body?*

Please describe any sores/lesions on its skin (Location on body, etc.)?*

Is your pet scratching at its ears?*

Yes

No

If so, which one?*

Is your pet shaking its head?*

Yes

No

Is your pet painful when you touch its ear(s)?*

Yes

No

Do you clean your pets ears?*

Yes

No

If so, what do you use to clean them and how often?*

Please list any other concerns you have about your pet or procedures you would like performed today if possible based on your pet's condition (toe nail trim, vaccines, etc.):*

Please list all medications your animal is receiving:*

Please list any treatment you have performed for your pet's abnormal signs (shampoo, over the counter medications, bandage, ointments/creams, etc.):*

I understand that I will assume financial responsibility for all services rendered at the time of discharge.*

Please select the one of the following:*

CPR- I authorize appropriate life saving measures. I understand and assume all financial responsibility for these additional fees that are not included in your treatment plan.

DNR- I do not wish for life saving measures to be performed. I am electing “DO NOT RESUSCITATE” status for my pet.

Date*

MM slash DD slash YYYY

Signature*

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