Out-Patient (Drop-off Appointment) Form
Please answer the following questions so that we can better serve you and treat your pet.
Owner's Name
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First Name
Last Name
Pet's Name
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Today's Phone Number
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Format: (000) 000-0000.
Has your address or phone number changed since your last visit?
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No, everything is the same.
Yes, my phone number has changed.
Yes, my address has changed.
Yes, both have changed.
Other
If any of your information has changed since your last visit, please enter the new information below.
1. Do you have a doctor preference? Please understand that while we will attempt to accommodate your request, not all doctors work every day, and your preferred doctor may not have an opening today.
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Yes
No
2. If yes above, my preferred doctor to see my pet is:
Please Select
Dr. Kevin Brumfield
Dr. Sondra Brown
Dr. Kathleen Cavell
Dr. Jennifer Smith
Dr. Alicia Smith
Dr. Jennifer Fleck
Dr. Noah Brown
3. Our doctor will perform a comprehensive examination of your pet today. Once that is performed, they may recommend procedures or testing to further help your pet with any conditions they find. Please select one of the below options.
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After examination, please perform all recommended test/treatments and discuss the results with me afterward. I understand that I will be responsible for all charges at checkout.
After examination, please CONTACT me with an estimate of cost for recommended tests or treatments before performing them.
The doctors and staff at Northwood Animal Hospital utilize multiple communication methods for updates on your pet throughout the day, which may include phone calls, text messages with or without photos, or email. Please let us know if you have any concerns about communication methods.
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Please Select
No concerns.
I will advise of my concerns at check-in.
4. Please give a brief description of the reason for visit.
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5. Please list any additional procedures you would like performed while your pet is here today (nail trim, anal gland expression, etc). Please understand there may be additional costs associated with any procedures performed.
I understand that my pet will be utilizing supplies and staff attention today, and that because of that I will be charged $5.00 for the boarding over the course of the day.
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Initial here
By signing below with my finger or mouse, I attest that I understand that payment for all services is due at the time of pick-up.
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Submit
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