Patient Drop Off Form Download and Print FormPatient Drop Off FormPatient Name*I would like my pet to be examined for the following problem(s):*Phone number where we can reach you:*My pet is strictly:* Indoors Outdoors BothPlease select any of the following symptoms you have noticed:* Vomiting Diarrhea Itching Excessive thirst Sneezing Bad breath Coughing Limping Hair loss Weight loss Change in appetite Weakness Scooting Flaky skin Scratching ears Shaking head Fleas/Ticks Worms Soreness Difficulty urinating Frequent urinationHave you noticed any additional symptoms? If so, please list here:Previous Surgeries:Previous Medical ConditionsCurrent DietAmountWe may need to draw blood on this visit. Has your pet eaten today:* Yes NoPlease list any medications your pet is currently taking (including heartworm and flea medication):Lumps, bumps, tumors, and skin lesions:Do you have pet insurance? Ask us how we can help you submit your claims!* Yes NoOur goal in examining your pet is to treat those problems that you are concerned about, and to check for any additional problems that may exist. After an examination is performed, the Doctor or technician will discuss any findings with you and make treatment recommendations.* I certify that I am the owner of the above listed pet, or I am responsible for him/her. I hereby consent and authorize Forest Crossing Animal Hospital to receive, examine, and prescribe medication for my pet. I assume full financial responsibility for this pet and understand that payment for services rendered is due at the time of pick up of my pet.If a staff member is able to stay past closing to accommodate a late pick up, a charge of $49.50 will be added to your account. If you have requested an after-hour pick up and are unable to get your pet by 6:30 a charge will be added to your account of $49.50 + a boarding fee that best accommodates the size of your pet.Signature*CAPTCHAΔ
