Drop-off Information Sheet Form

Client Name

Pet's Name

Phone Number to be reached at today

Procedures/Treatments to be performed

Physical ExaminationVaccine UpdateDewormingBathAnalNail TrimBlood WorkUrinalysisBoardingRadiographsVOM AdjustmentOther

If other, please specify

Please provide a brief description of your concerns for today?

Is your pet on any medications?

Yes

If yes, what medications?

Has your pet eaten this morning??

Yes

If yes, at what time?

What is your pet's diet?

Any vomiting?

Yes

Any diarrhea?

Yes

If yes, for how long?

Is your pet on monthly flea control?

Yes

If yes, what kind?

*All pets admitted with fleas or ticks will be treated at the owners expense with a 24hr capstar at an additional cost of $10.11- $10.20 per treatment depending on the pets weight*

If an emergency where to occur what CPR would you like MVC to perform? (Circle one please)

0 - Do not resuscitate

1 - CPR Grade 1 (Minimal Attempt; injection) $96.00

2 - CPR Grade 2 (Chest Compressions) $239.50

3 - CPR Grade 3 (Do all that's necessary, including opening the chest) $529.50

I authorize the use of my pet's picture to be portrayed in a positive matter for the purpose of teaching/learning and social media.

AUTHORIZATION FOR EXAMINATION, TREATMENT, AND ASSUMPTION OF ALL FINANCIAL RESPONSIBILITES:

I, the undersigned, authorized the veterinarian(s) and their staff to examine the patient specifically described and identified above and to administer any medical, surgical treatments and/or test, including sedation or anesthesia which is considered necessary based on findings during the course of examinations. I assume responsibility for all charges incurred for services rendered to the patient upon pick up this pet.

Owner or Authorized Agent

Date

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