Walton Way Veterinary Clinic
Drop off Form
Owners Name:_________________________________________ Date:____________________________
Pet’s Name:_____________________ Species:________ Breed:________________ Age:________ Sex: M/F
Phone number where you can be reached at today:________________________ Best time to call:________
Pet’s current medications:__________________________________________________________________
Have medications been given today?________ If yes, please list:____________________________________
Allergic to any vaccinations or medications:____________________________________________________
Current Diet:_____________________ How much:____________________ How often:_________________
Did your pet eat this morning? Yes or No Regular diet or other:___________________________________
Appetite: (Circle one) Normal/Increased/decreased or other:______________________________________
Does your pet get table scraps? Yes or No Food Allergies? Yes or No - If yes, please list________________
Choose one of the following:
___ My pet is here for :  Routine Services  Bloodwork_____________ Radiographs
___ My pet is here for a recheck of:____________________________________________
___ My pet is sick
If sick, please complete the following:
My main concern is _________________________________________________________________
Has your pet been treated before for the same complaint? Yes or No
Length of illness or changes in pre-existing conditions:______________________________________
Please check ANY symptoms or problems you have noticed about your pet:
Behavior Changes
Discharges, explain:_______________ Shaking Head
Bleeding Gums
Gagging
Sneezing
Breathing Problems
Limping, which leg________________ Urination Decreased
Coughing
Loss of balance
Urination Increased
Depression
Scooting
Vomiting
Diarrhea
Scratching
Weakness
Lump, where?_____________________
Other:____________________________________
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Vaccinations: All needed All Current – Please provide medical record
Dogs:  Distemper/Parvo  Bordetella  Rabies Heartworm Test Parasite Check
 Distemper/Parvo Titer Annual Bloodwork Profile
Is your dog on monthly heartworm prevention? Yes or No Rx Name:______________________
Flea/tick prevention? Yes or No Product name:_______________________________________
Cats: All needed All Current – Please provide medical record
Fvrcp Leukemia FIV/FELV test Parasite check Annual Biochemical profile???
Is your dog on monthly heartworm prevention? Yes or No Rx Name:______________________
Flea/tick prevention? Yes or No Product name:_______________________________________
Is your cat: Indoor Only Outdoor Only Both
Do you have other cats? Yes or No How many?__________________________
Other Services:
Ear cleaning Toe Nail Trim Bath Other, please list____________________________________
To promote the diagnosis of your pet, please authorize or decline the following:
Authorization for bloodwork if needed: Yes No Call before
Authorization for x-rays if needed: Yes No Call before
Authorization for sedation if needed: Yes No Call before
As determined by the veterinarian, some pets require sedation/general anesthesia for an adequate physical exam,
treatment or surgery. Our clinic uses the safest protocol for your pets. By answering “YES” you understand that there is a
risk involved when you sedate any animal.
STATEMENT OF OWNERSHIP AND CONSENT: I am the owner and/or agent of the above animal and I authorize WWVC staff to
provide care and perform any treatment, including the administration of anesthesia and surgical procedures they consider
reasonable and necessary for my animal, and I consent to any such services. I understand that with any medical or surgical
procedures there are always risks involved, including death, and that no warranty or guarantee is being made as to the results or
cure. I Additional charges will accrue if my animal is not picked up on the day he or she is ready to be released from the hospital. I
will be responsible for all charges incurred. I understand that all veterinary services are to be paid for at the time such services are
provided. All unpaid checks and delinquent accounts will be transferred to a collection agency.
Owner/Authorized Caregiver Signature (Required): ________________________________________ Date: ___________
Additional Phone Number(s) to be reached at:___________________________ or ______________________________
Please call the office (2) hours after your drop off to check on the status of your pet and in case we have not been able
to get in touch with you as needed.
Drop-offs are scheduled for discharge after 4p.m.