Drop Off Form – Blackfalds Veterinary Hospital in Blackfalds, Alberta

Client Name

First Last

Pet Name

First

Where I can be reached today

Lethargic

Yes
No

Coughing / Sneezing

Yes
No

Constipated

Yes
No

Having Diarrhea

Yes
No

Blood Present?

Vomiting

Yes
No

Blood, bile, food? Last Vomited?

Change in drinking?

Yes
No

More? Less?

Change in eating?

Yes
No

More? Less? Anything other than food?

Change in urination?

Yes
No

Increase/Decrease?

Limping

Yes
No

Which Leg?

Scratching / Licking

Yes
No

Where?

My pet was healthy until

Since then the symptoms also include

My pet is on the following medications

Sensitivity / Allergy Exists to

Is there anything else we can do for your pet today?

Vaccines
Nail Trim
Anal Gland Express
Microchip Implant

I, as the owner/ agent for the above named animal, authorize and request an exam for my pet. I understand that sedation and/ or pain medications will be provided if deemed necessary. I understand that the Veterinarian will contact me after he/ shehas examined my pet to discuss recommended diagnostics and treatment, and will have an initial estimate ofcharges before any treatment is done.

If I can not be reached at the above numbers, I authorize initial diagnostics, including radiographs and blood work if indicated for my pet. I assume financial responsibility for these procedures.*

Yes
No

Signature*

Date*

MM

DD

YYYY