Sick Patient Drop Off Form

Client Info

Client Name
Address

Patient Info

Please select all that are applicable:
Water intake has

If I cannot be reached at this number, I authorize inital diagnostics, including radiographs, and blood work if indicated for my pet. Further, if I cannot be reached, I authorize initial treatment, including fluid support and other supportive medications be started as indicated for my pet.

I authorize anesthesia, surgery and medications if need for abscess, laceration or other wounds, if my pet is presented for any of these problems. I understand and accept that when anesthesia is involved, there is always inherent risks, including death.

I  understand  payment  is due when  my pet is discharged and I accept financial responsibility for charges incurred for this pet.

Preferred Doctor
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