Drop-Off Client Form Drop-off Client Form Date * Client's Name * Client's Name First First Last Last Pet's Name * Breed * Phone number to reach you today * Email * Reason for drop-off/examination (please be as thorough as possible) Did your pet eat this morning? * Yes No Current Diet * Is your pet currently on any medication(s)? * Yes No If Yes, please list the medication(s) and when last dose given * If deemed medically necessary by the Doctor, I authorize the following care for my pet Fecal analysis ($36.25 - $51.00) * Yes No Complete blood count ($90.50 - $98.50) * Yes No Blood chemistry profile ($185.50) * Yes No Radiographs (X-rays) ($140.00 - $163.00) * Yes No Sedation ($23.00 - $81.00) * Yes No If fleas or mites are noted on pet upon intake, I understand I will be charged $20.00 - $65.00 for treatment. * I understand All drop-offs for sick animals must pay the total amount of the estimate at the time of dropping off OR leave a $100 deposit plus the exam fee if no estimate provided. * I understand ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept: Mastercard / Visa / Discover / Am Ex / Check / Cash / Care Credit I, the undersigned, assume financial responsibility for all charges incurred, and agree to pay all such charges at the time these services are rendered or arranged prior to examination and/or treatment. Signature of person responsible for payment * signature keyboard Clear Date * If other than client please print name and relationship to client Captcha Submit If you are human, leave this field blank.
