Patient Drop Off and Treatment Authorization Form
Your Name: _____________________________ Pet’s Name: _______________________________
Best Phone Number(s) to reach you at:
Home/Work
Cell
How can we help your pet today?
Has your pet ever had a vaccine reaction?
If yes, please explain:
Is your pet allergic to any medication?
If yes, please explain:
Pet’s appetite is …: (circle one) NORMAL
DECREASED
Drinking …: (circle one) NORMAL DECREASED
INCREASED
INCREASED
What do you feed your pet? ____________________________ When did your pet last eat? __________________
Is your pet experiencing any:
Vomiting? ______ If yes…How often? ________________ For how long? ___________________________
Diarrhea? ______ If yes… How often? ________________ For how long? ___________________________
Sneezing? ______ If yes… How often? ________________ For how long? ___________________________
Coughing? _____ If yes…How often? ________________ For how long? ___________________________
Itching? _______ If yes… How often? ________________ For how long? ___________________________
Pain? _________ If yes….How often? ________________ For how long? ___________________________
Is your pet (circle one):
INSIDE ONLY OUTSIDE ONLY BOTH
Please list any medications/vitamins/supplements your pet is taking. (This includes heartworm and flea
prevention.)
Are there any other problems that you would like the doctor to address today?
**Please note that our hospital is Flea Free. If fleas are found on your pet, treatment will be performed at your expense. **
Please INITIAL one of the options below
I give Buttercup Veterinary Hospital permission to treat the above listed patient as needed not to exceed:
____ $100 _____ $200 _____ $400 _____ $600 _____ Treat as needed
______ Please do not perform ANY treatment(s) on my pet until I (or my representative ______________) can be contacted.
I
**I have read, understand and accept the hospital drop off policy of Buttercup Veterinary Hospital. I accept that
I assume financial responsibility for all services rendered and that full payment is due at the time of pick up.
(Payment can be made with Visa, MasterCard, Discover, Debit, Cash, or Check with a valid I.D.)**
Financially Responsible Person:
Date: