Drop-Off Registration Form

Canine Drop-Off Registration

Please fill out the following form! If you have any questions, please feel free to contact us.

Canine Drop-Off Registration

To ensure your pet gets the best care we can offer, please fill out the form completely. Please Note: All * fields are required.

Canine Drop-Off Registration Form

Owner Name *

First

Last

Phone *

Email *

Would you like to receive updates for Newsletters, Client Service Notes and Reminders through email?

Pet's Name *

Animal’s Possessions

Procedure *

Procedure Date *

Procedure Authorization

I hereby authorize performance of the procedures listed above. (If unexpected results are found which require immediate attention, veterinarian will call you to discuss treatment options.) *

If I cannot be reached at the number provided, I authorize the veterinarian to treat my animal as they deem necessary for their well being. I understand this may include additional expense.
If I cannot be reached at the number provided, only provide the treatments listed above.

Microchip

Every two seconds, a family pet is lost. Many are never reunited with their families because they cannot be identified. Because of these statistics, we suggest microchips whenever a pet is sedated. HomeAgain chips are known nationwide and have a 24-hour hotline to match chip numbers with the owner’s contact information.

Our records indicate your animal ’s microchip number is:

No microchip?

My animal does not have a microchip, please implant one during their procedure. I understand that the cost of the microchip is $68.00 in addition to the cost of procedure.
I hereby decline the implanting of a microchip.

Parasite Control

For the protection of all our patients, any pet left for treatment will be inspected for external parasites (fleas, ticks, etc.). If parasites are found, we will apply the appropriate topical treatment at the single dose price. Please list any flea, tick or ear mite medication recently applied.

CPR/DNR statement

All patients being treated are required to have an advanced directive in the form of a CPR (Cardiopulmonary Resuscitation) or DNR (Do Not Resuscitate) code. Please select ONE option below.

I request CPR on my pet if my pet suffers from a cardiac or respiratory arrest. I understand that CPR does not guarantee that my pet will have a favorable outcome. Further, I understand that there are fees associated with CPR that would increase the cost of my pet’s care while the hospital is making every effort to contact me.
I DO NOT want CPR performed on my pet. I have elected to have a DNR order placed on my pet’s record. I understand that my pet will pass away in the event of cardiac and/or respiratory arrest.

I am the owner or responsible agent for the patient, and I have the authority to provide this advanced directive. I am over the 18 years of age. *

I have read and agree

Owner/Owner’s Agent Name *

First

Last

Signature *

Today's Date *

Canine Drop-Off Registration

Canine Drop-Off Registration

Canine Drop-Off Registration Form

Procedure Authorization

Microchip

Parasite Control

CPR/DNR statement

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