Pet Drop Off Consent Form

Pet Drop Off Consent Form
Name of Pet Owner
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Pet
Chief Complaint
Is your pet experiencing any of the following:
DiarrheaItchinessVomitingLimpingWeakness
Any behavioral changes with the Pet?
Any changes to appetite of pet?
Any medications that the pet is currently receiving?
By dropping off your pet, he/she will be monitored Your pet will be monitored. We will get in touch with you in any event with regard to your pet that requires that you be notified. In any event, you may reach us out by calling us at 304-303-3303.
I hereby give my consent in authorizing the pet clinic for the treatment for my pet as may be deemed appropriate. I authorize the medical charges that may be required that is necessary for the treatment and care for my pet. I understand my financial obligation shall be due at the time of discharge from the pet clinic.
Signature
Clear
Should be Empty: