Drop Off Questionnaire If you are dropping your pet off, please fill this out for us! Name on File* First Last Name of Pet* Pet's Name Phone to reach you at*Drop off Date* MM slash DD slash YYYY Pickup Time* : Hours Minutes AM PM AM/PM Why are you dropping your pet off?*Vaccines/Nail Trim/Anal Glands ONLYSick/Injured/Lame/Ears/EyesSelect all that you want your pet to recieve* Vaccines Nail Trim Anal Glands expressed What species are you dropping off?*DogCatLarge AnimalDo you approve the recommended annual exam for dogs at $145*YesNoThis includes: Wellness Exam, Rabies, DA2PP/L4 (combo), Bordetella Oral, Heartworm Test, and a FecalDo you approve the recommended annual exam for cats at $160*YesNoThis includes: Wellness Exam, Rabies, Felocell CVR, Leukemia Vaccine, Leuk/FIV/Heartworm Test, and a fecal.What are you wanting done with your large animal?*Please select all that apply regarding Monthly meds* My pet is NOT on any monthly meds My pet is on Heartworm prevention My pet is on Flea/Tick prevention What Monthly meds do you give?What is Wrong with your pet?*When did problem first start?* MM slash DD slash YYYY Has condition improved or worsened since starting?*ImprovedWorsenedStayed the sameHave you tried any treatment for this problem?*Yes, with another vet's helpYes, with over the counter helpNoIf yes with another vet, you can upload the files below.What treatment did you use and what were the results?*Upload previous records hereMax. file size: 256 MB.Is your pet inside/outside/both?*InsideOutsideBothWhat do you feed your pet?*Please select all that apply regarding food/treats* I have NOT changed my pet's food I HAVE changed my pet's food My pet does NOT get table scraps My pet DOES get table scraps My pet does NOT get treats My pet DOES get treats Is your pet's vaccines current?*YesNo, do not updateNo, update if able (based on health of patient)Was your pet previously vaccinated through us?*YesNoYou can upload previous records below if not vaccinated with usUpload Records hereMax. file size: 256 MB.Other Information NeccessaryPlease answer normally, or pick the best 'abnormal' answer for the following questions.Eating* Normally Less More Pickier Drinking* Normally Less More Acting* Normally Lethargic More energized Abnormally Urinating* Normally Less More Defecating* Normally Runny/Diarrhea Hard Stools Abnormally Sleeping* Normally Less More Seeing* Normally Less Abnormally Breathing* Normally Shallow Heavy Vomitting* Yes No Coughing/Gagging* Yes No Scratching* At Skin At Ears Chewing at Tail head Chewing at Feet Chewing at 'flank area' None of the above Shaking Head* Yes No Have Hair loss* Yes No Weight* Same Loss Gain Limping* Yes No Which Leg/paw*Please specifyBehavior Problems* Yes No Describe Behavior issuesIf you already have prior to, disregardShowing signs of pain* Yes No Have eye problems* Yes No Does abdomen feel enlarged* Yes No Final InformationWould you like us to call prior to doing any treatments or tests?*Yes, phone number above is fineYes, I'll give a different phone numberNoPhone Number to call*Bloodwork Approval By clicking the box, I am approving bloodwork and its associated cost.A full blood panel can cost up to $105. A blood panel allows us to recognize underlying abnormalities easier. While we may run a smaller, specified blood test under the $105 amount, if you are uncomfortable with this, we will call you and discuss this option if we feel it is necessary.Radiograph Approval By clicking the box, I am approving up to 4 radiographs and its associated costRadiographs can help us narrow down the issue being experienced with your pet. Four radiographs can cost up to $187. We may not need 4 radiographs, but to get different angles, it may be necessary. If we need more views, we will call you.
