Client Name (required)
|
Cell Phone Number (required)
|
E-Mail Address (required)
|
How would you like to be contacted during the curbside appointment time? (required)
|
Make, Model, and Color of Vehicle you will be arriving in (required)
|
In the event of an emergency requiring resuscitation (anaphylactic or anesthetic reaction, cardiac arrest, etc) (required)
|
Patient Name (required)
|
Summary of your concerns with your kitty (required)
|
Current Medications |
Please list as medication name, dosage, directions for use, and when it was last given (Ex: Cerenia 16mg - 1/2 tab every 48 hours - Last Given: 1/2/18 at 3pm) (required)
|
Feeding Information |
Canned Food Brand (required)
|
Flavor (required)
|
Amount (required)
|
Dry Food Brand (required)
|
Flavor (required)
|
Amount (required)
|
Please answer the questions below to help us better help your kitty |
Has your cat vomited or had hairballs in the last 30 days? (required)
|
What is your cat's lifestyle? (required)
|
Have you noticed any changes in the following areas? |
Appetite (required)
|
Water Consumption (required)
|
Urination (required)
|
Defecation (required)
|
Activity Level (required)
|
Reluctance to jump or run (required)
|
Limping (required)
|
Itching/Hair Loss (required)
|
Nasal/Ocular Discharge (required)
|
Sneezing (required)
|
Coughing (required)
|
Behavior (required)
|
History of fight wounds (required)
|
If yes to any of the above, please explain (required)
|
Curbside/Drop Off Consent |
I am the owner or agent of the cat named above and have the authority to execute this consent. I understand that during the performance of procedure(s)/operation(s), unforeseen conditions may be revealed that necessitates an extension of the foregoing procedure(s)/operation(s) or different procedure(s)/operation(s) than those provided in the treatment plan. I hereby consent to authorize the performance of such procedure(s)/operation(s) as are necessary and desirable in exercise of the veterinarian's judgement. I have been advised as to the nature of the procedure(s)/ operation(s) and the risks involved. I realize that the results cannot be guaranteed. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. To prevent the spread of infectious disease, any cat with fleas will be treated with an oral and/or topical medication upon admission to the hospital. The price of the treatment will be added to your invoice. I have read and understand this authorization and consent. By submitting this form I hereby consent and authorize the performance of the procedures that I have approved in the treatment plan. I agree to pay all charges incurred when my cat is released from the hospital. |
Please initial below if you have read the above and authorize the performance of the estimated treatments/procedures (required)
|
Processing ....