DROP OFF FOrm

Please complete the drop off form below. If you have any questions please contact us.

Appointment

Online

drop off Form

Client's Name *

First

Last

Phone *

Pet Information

Pet's Name

Problem(s) for which your pet needs to be seen:

When was the problem first noticed?

Has the problem gotten worse?

Yes
No

Has your pet vomitted?

Yes
No

Has your pet had diarrhea? *

Yes
No

Has your pet had any unusual sneezing or coughing? *

Yes
No

What did your pet eat/drink last, and when? (Day andTime) *

List any medications given to your pet within the last week:

Beyond examination, some tests may be required to effectively diagnose and treat your pet for the above problem(s). I understand that if emergency medical care is needed, my pet will receive the treatment that is necessary while every attempt to contact me is made. Please choose ONE option below as to how you would like the doctor to proceed:

I authorize the doctors/staff of GoldenView Veterinary Hospital to perform any diagnostic tests, treatments, and/or sedation/anesthesia deemed necessary for my pet.
I authorize any tests/treatments deemed necessary, but I would like to be contacted for further authorization if the charges are expected to exceed a specific amount (list below).
I prefer to be contacted after the doctor has examined my pet to discuss any testing or treatment that will be recommended, before it is done.

If I selected option B or C, I understand I may need to sign an additional authorization for medical care. Please select fax or email below to receive the Treatment Plan. I will sign and return the Treatment Plan to authorize the care and acknowledge the expected fees.

Fax
Email

Signature

Date / Time

DROP OFF FOrm

Online

drop off Form

Pet Information

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