Seaside Animal Care
Drop-off Patient Consent for Treatment Form

Forms need to be completed 24 hours prior to services unless otherwise directed. You will be contacted via telephone or email regarding confirmation of your appointment request.
* Required Fields
Name*
Address
City State Zip
E-Mail*
Home Phone
Pet's Name*
Expected Arrival Date* Expected Arrival Time*

Routine Services
(Please check all services to be performed)
Canine Vaccinations
Rabies
Distemper 1 year
Distemper 3 year
Bordetella-6
Lyme 		Feline Vaccinations
Rabies
Feline Distemper
Feline Leukemia
FIP
Diagnostic Tests
Physical Exam
Intestinal Parasite Exam/Fecal
Heartworm Antigen/Lyme/E.Canis Test (Canine ONLY)
Feline Leukemia/FIV Test (Feline ONLY)
Routine Blood Work
Senior Blood Work (7 years or older)
Spa Services
Hypoallergenic General Purpose Bath
Medicated Bath (as determined by vet)
Nail Trims
Medical

Primary Complaint(s):
(Please check all that apply)
Vomiting  Diarrhea   Blood in Stool   Coughing   Sneezing   Difficulty Breathing   Lameness or Limping
Urinating Frequently   Unable to Urinate   Urinating in Unusual Places   Blood in Urine   Bite Wound(s)
Itching   Hair Loss   Lethargic or Depressed   Not Eating   Losing Weight   Abnormal Behavior
Ate or Swallowed Something Unusual   Check a Growth or Tumor   Pain   Ear Problem
Other

Specify Complaint(s): (e.g. left leg, growth on face, at a bone, hiding, etc.)

Duration of Condition(s): (e.g. hours, days, weeks, etc.)


Please list any medications and/or diet your pet receives:

Please use text area below to provide other information we might need to know about your pet's and their special needs and/or requests:

Consent for Treatment:
The actual cost and nature of medical services will be determined by the attending veterinarian. If the actual anticipated cost exceeds 10% of the maximum estimated cost, Seaside Animal Care will require your authorization before proceeding with further treatment. In the event that a life-threatening condition should develop and we are unable to contact you, we will proceed with any and all life-saving measures available. By submitting this form, you are authorizing Seaside Animal Care to proceed and accept full financial responsibility for all diagnostic tests and treatment included in the above estimate for services and for any additional emergency services should they be necessary. Additionally, by your digital signature, you are verifying that you are at least 18 years of age. Payment is expected at time of discharge unless prior arrangements have been made and approved by our hospital office manager.

Telephone Number where you can be reached today:*



Check this box if you would like to receive an estimate for services via email.

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