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Drop Off Form

Please fill out the following form as thoroughly as possible before your scheduled appointment. Please note: All * fields are required. If you have any questions, please don’t hesitate to call us.

Client's Name *

First

Last

Phone Number where you (client/owner) can be reached ALL day today *

PET HISTORY

What vaccinations is your cat currently on?

Rabies
FVRCP
FELV
FELV/FIV Test

Do you want to update vaccines?

What vaccinations is your dog currently on?

Rabies
DHLP+Parvo
Bordetella

Do you want to update vaccines?

Is your pet on heartworm preventive?

Has your pet been checked for intestinal parasites in the last 6 months?

Did your pet eat this morning?

Is your pet allergic to any medications?

Has your pet had any illness or injury in the past 30 days? Any current concerns?

Any history of seizures and/or previous anesthetic problems?

Current medications?

Authorization to provide care

I am the owner or agent for the owner of the above-described animal and have the authority to execute this consent. I hereby authorize and direct Foothills Animal Clinic, its veterinarians, technicians, and assistants to perform services, procedures, diagnostics, vaccinations, treatments, and/or administration of extra label medications as deemed necessary or advisable in connection with or relating to the matters described in the attached estimate or the matters that have otherwise been explained by Foothills Animal Clinic veterinarians or other Foothills Animal Clinic associates. *

Clear Signature

Sign here

I understand that there is a risk of complications with every procedure, including the possibility of death as a severe complication of surgery, anesthesia, or other procedures. I also understand that there is no guarantee as to the results of any procedures, diagnostics, vaccinations, or treatments. I understand that I may ask any questions regarding any procedure, diagnostic, vaccination, or treatment recommended by the Foothills Animal Clinic veterinarian before it is performed. *

Clear Signature

Sign here

I understand that there may not be a veterinarian at the hospital at all times. I understand that veterinary technicians or assistants may perform certain functions in the preparation and care of my pet even when a veterinarian is not present. I also understand that no staff will be present in the hospital overnight. Unless the veterinarian advises that my pet may remain unattended in the hospital overnight, I will need to take my pet or transfer to a hospital offering overnight care at the end of the day. If I fail to pick up my pet before the hospital closes for the day, Foothills Animal Clinic may transfer my pet to a hospital offering overnight care if the veterinarian determines my pet cannot be left unattended overnight. I understand and agree that I am responsible for the payment of any charges of such overnight care. *

I agree
I decline

I agree that hospital staff may walk my pet outside. I understand that in the event of an emergency, it may be necessary for my pet to be taken to an emergency hospital. I authorize Foothills Animal Clinic and its veterinarians and other personnel to transport my pet to an emergency hospital and to obtain treatment by the emergency hospital to stabilize my pet if I cannot be reached. Foothills Animal Clinic and its personnel may disclose such information and records regarding my pet to the other hospital as they consider necessary. *

I agree
I decline

I understand that payment is due, in full at the time of services are rendered. I understand it is my responsibility to call the hospital daily, to be updated on my pet, and the costs incurred for medical services during that day. If I do not call or I can not be reached, I understand it is my responsibility to pay what is due. I understand that Foothills Animal Clinic does not request or require personal information as a condition to payment by credit card, but card users may be required to provide proof of identity. If for any reason payment is not made at the time services are rendered or within 10 days thereafter, I understand that my account may be referred to a collection agency. In the event that my account is referred to a collection agency, I agree that Foothills Animal Clinic may add an amount to my outstanding account balance to reimburse Foothills Animal Clinic for the reasonable collection charge (but not including attorney’s fees) imposed by the collection agency. *

I agree
I decline

If I neglect to pick up my pet within 7 days, Foothills Animal Clinic may assume that my pet has been abandoned and is authorized to make such arrangements as it may deem best. *

I agree
I decline

I understand and agree that portions of my visit or care and treatment of my pet may be recorded for educational purposes. *

I agree
I decline

If an unexpected life-threatening emergency take place (Please initial one): *

I authorize the hospital staff to perform CPR and provide treatment up to the mentioned amount.
I do not want CPR performed.

If you authorize, please mention the amount below ($ Up to):

Date *

Drop Off Form

Drop Off Form

PET HISTORY

Authorization to provide care

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