Drop off Questionnaire & Consent Name * First Name Last Name Email * Phone * (###) ### #### Describe the reason for your pet's visit today and list all symptoms: * How long has your pet been displaying these signs? * When was the last time your pet ate? * What did they eat? * Is your pet on Heartworm medication? * Yes No Is your pet on flea and tick prevention? * Yes No Percent of time your pet spends indoors: * and outdoors: * Please list any medications your pet is currently taking: * * I am the owner or agent of the above-described animal and have the authority to execute this document. I herby authorize the attending veterinarian to administer medical treatment as is considered therapeutic and/or diagnostically appropriate based on the findings during the course of evaluation. I consent to the administration of medications that are deemed appropriate by the attending veterinarian. I am responsible for all charges incurred during my pet's treatment and it is understood that payment is due at the time of service. I agree Thank you!