Drop off questionnaire

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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 *

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