DOVE CREEK ANIMAL HOSPITAL
PATIENT DROP-OFF FORM

“Your Other Family Doctor”

Do you have/know of any other pets with similar symptoms?

Has your pet been seen by other Veterinarians for this problem?

How is your pet’s energy level?

Is there any change in your pet’s water consumption?

Are there any new or strange odors from your pet?

Does your pet have any trouble breathing?

Does your pet scratch excessively?

Does your pet show any behavioral or neurological symptoms?

Is your pet taking any medications?

Does your pet need any medication refills at this time including flea/heartworm prevention?

If an emergency occurs while your pet is in our care and life saving decisions must be made in your absence, please select from the following options:

NOTE:  ALL HOSPITAL CHARGES ARE DUE UPON DISCHARGE

What is your preferred method of payment?

I agree to the following terms:

Authorization to Provide Care:  I am the owner or authorized agent of the pet named on this form.  I hereby authorize and direct the Veterinarians or associates of Dove Creek Animal Hospital to perform any/all procedures, diagnostics, and treatments for my pet(s).  I authorize Dove Creek Animal Hospital to obtain all medical records regarding my pet(s).  I fully understand there is a risk of complications with any medical procedure, surgery, or anesthesia including the possibility of death.  The nature and risks of such complications have been, or will be explained to me, or I will see that they are explained to me and any questions I may have will be answered before I leave my pet(s) for any treatment.  I understand that the staff of Dove Creek Animal Hospital will not be present in the hospital overnight and that any portion of my visit may be video/audio recorded for training purposes.  I understand that there is no guarantee, nor can one be made as to the results of any therapy.

If I neglect to pick up my pet(s) with 7 days of the drop off date listed on this form, Dove Creek Animal Hospital is to assume that my pet(s) has/have been abandoned and is authorized to make other arrangements as they may deem necessary.  I agree to pay in full for all services rendered.  I understand that payment is due and expected on the day service is rendered.  If for any reason payment is not made at that time or within 10 (ten) days thereafter, that my account may be referred to a collection agency.  In such event that my account is referred to a collection agency, I agree that Dove Creek Animal Hospital may add an amount to my outstanding balance to reimburse them for any reasonable collection charge (but not including attorney fees) imposed by the collection agency.  In the event of an emergency or as determined by a Veterinarian, it may become necessary to take my pet(s) outside the hospital.  I authorize Dove Creek Animal Hospital to walk or transport my pet(s) outside the hospital.  I understand that Dove Creek Animal Hospital will exercise every reasonable precaution to ensure the safety of my pet(s) while in their care and unforeseen events will not relieve me of my financial obligations.

Thank you for your message. It has been sent.
There was an error trying to send your message. Please try again later.