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Drop off questionnaire
GFPC Drop off form:
*
Indicates required field
Name
*
First
Last
Pet's name
*
Phone Number
*
Alternate phone number:
*
Reason for today's visit:
*
Start date of clinical signs:
*
When did you notice that your pet is not feeling well?
Diet
*
What is your pet eating at home?
Medications
*
Is your pet on any medications/supplements?
Attitude
*
Bright & Alert
Depressed/Lethargic
Quiet
Appetite
*
Increased
Decreased
Not eating at all
Unchanged
Water intake
*
Unchanged
Decreased
Increased
Vomiting?
*
Yes
No
If yes, how often?
*
Diarrhea
*
Yes
No
If yes, how often? What consistency and color?
*
Urination
*
Normal
Blood
Dark
Straining
Strong/foul odor
Not passing any urine
Coughing
*
Yes
No
Sneezing
*
Yes
No
Allergies
*
Yes
No, not that I know of
If yes, please explain what is your pet allergic to:
*
Additional comments & Requests
*
I am the owner or authorized agent of the animal presented for care. If anesthesia or sedation is required, I understand, and accept that there are always inherent risks, including death. I also authorize the clinic staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me is possible Please note that the examination fee is $102+ tax and an additional $10 drop off fee may apply and by submitting this form you agree to have the pet admitted in the hospital and examined by a veterinarian. I understand that I am responsible for the costs of all treatments performed today and payment is due in full when I pick my pet up later today. Please initial in box below:
*
Initial below:
Submit
Welcome
About Us
Clinic News
Meet Our Team
Clinic Photos
Referrals
Ultrasound Referrals
Book An Appointment
Services
Wellness Exams & Vaccines
Surgical Procedures
>
Canine & Feline Spays & Neuters
Exotic Spays & Neuters
Dentistry & Dental Health
Surgery Drop-Off Instructions
Nutrition & Behavior Consultations
>
Common Pet Food Myths
Radiology & Ultrasonography
Exotics Services
Pharmacy & In-House Laboratory Services
Euthanasia
Emergencies
Contact Us
Online Store
Payment Options
Prices & Fees
Exam fees
Dog spay price
Dog neuter price
Cat spay price
Cat neuter price
Bunny spay price
Bunny neuter price
Puppy series info
Kitten series info
Animal blog
Drop off questionnaire