Client Name (required)
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Cat's Name (required)
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Best phone number to reach you at (required)
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E-Mail Address (required)
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Current Medications (required)
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Do you need refills of any medications?
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What canned food brand, flavor, and amount are you feeding? (required)
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What dry food brand, flavor, and amount are you feeding? (required)
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Has your cat vomited or had hairballs in the last 30 days? (required)
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What is your cat's lifestyle? (required)
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Have you noticed any changes in the follow areas? (required)
Appetite
Water Consumption
Urination
Defecation
Activity level
Reluctance to run or jump
Limping
Itching/hair loss
Nasal/ocular discharge
Sneezing
Coughing
Behavior
None of the above, my cat is purrfect
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If yes to any of the above, please elaborate and/or summarize any and all concerns (required)
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In the event of an emergency requiring resuscitation (anaphylactic or anesthetic reaction, cardiac arrest, etc) (required)
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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)
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