Drop-off Medical Services 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.

Information

Name:

Address:

City: State: Zip:

Email*:

Home Phone:

Pets Name:

Expected Arrival Date*:
Expected Arrival Time*:
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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
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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:*

Would you like to receive an estimate for services via email?  Yes No

Filed Under: Hospital Forms