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Convenient Drop off Appointment Release

Full Name(Required)

First Name

Last Name

Pets Name(Required)

First

Last

Phone Number(Required)

Secondary Phone Number

Email(Required)

[email protected]

Please ensure that you are available by phone at ALL times until your pet is released back into your care.

Please enter Diet and Feeding information.

Brand of Food(Required)

Amount per Feeding(Required)

Frequency of Feeding(Required)

Type of Treats(Required)

Frequency and Amount of Treats(Required)

Check the conditions that apply to your pet.(Required)

Coughing

Sneezing

Vomiting

Diarrhea

Eye Discharge

Dirty/Itchy Ears

Nasal Discharge

Limping

Skin Issue

New or changed lump

No concerns

Other

Other Condition

How long has this condition been going on for and with what frequency?

Has your pet experienced this condition in the past?

Check the symptoms that your pet is currently experiencing(Required)

Not eating

Trouble breathing

Trouble Defecating

Trouble Urinating

Weight gain

Weight loss

Change in behavior

Change in activity level

No concerns

Other

Other symptoms

How long has this symptom been going on for and with what frequency?

Has your pet experienced this symptom in the past?

Yes

Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.

Medication

Dose

Frequency

Do you need add another pet medication details?

Yes

Medication

Dose

Frequency

Do you need add another pet medication details?

Yes

Medication

Dose

Frequency

Has your pet ever had a reaction to vaccinations?(Required)

Yes

Not Sure

Please indicate what preventatives or medications you need a refill of

Bravecto

Interceptor

Simparica Trio

Revolution

Other

Other medication

Which preventative care procedures are you approving? (Select all that apply)(Required)

Rabies Vaccine

Distemper Vaccine

Bordetella Vaccine

Influenza Vaccine

Lyme Vaccine

Leptospirosis Vaccine

Feline Leukemia Vaccine

Intestinal Parasite (Fecal) Lab test

Heartworm/Tick Parasitology (Blood) test

Annual Full Organ Function Lab Screening

Urinalysis

Other

Other preventative care

Are there any other issues/concerns that you would like to discuss at your appointment?

Do you need add another issue?

Yes

Any other issues/concerns?

Do you need add another issue?

Yes

Any other issues/concerns?

I authorize VMVH the budget below to do what is necessary for my pet's care today. Anything beyond this amount will require a verbal authorization before continuing.

A topical treatment will be applied at the my expense to any pet with evidence of fleas, flea dirt, or ticks. I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital.

Authorization

I authorize VetMED Veterinary Hospital to do whatever is necessary should an emergency arise. Should be my pet become ill or inure itself, and VMVH is unable to contact me at the numbers that I have provided, my pet will be treated as deemed necessary by the attending dvm at my own expense.

Signature

Drop off Intake

Please ensure that you are available by phone at ALL times until your pet is released back into your care.

Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.