Walton Way Veterinary Clinic
Drop-off Form
Pet Name:____________________________ Owner Name:__________________________________
Reason for visit: (Check all that apply)
*Please inform us if your pet has ever had a reaction to vaccinations in the past*
Yearly vaccinations: Canine: Rabies Da2PP Bordetella Heartworm test Fecal test ($138.00)
Feline: Rabies FVRCP Feline Leukemia Deworming
($80.00)
All pets staying in our care are required to have the following vaccinations:
Canine: Rabies Da2PP Bordetella
Feline: Rabies FVRCP
Illness________________________________________________________________________________
Injury________________________________________________________________________________
Other________________________________________________________________________________
Any concerns? (Circle all that apply)
Appetite loss
Increase/Decrease in drinking
Vomiting
Diarrhea
Itching/Scratching
Decreased energy
Scooting
Limping
Shaking head
Weight gain/Loss
Other ___________________
Trouble getting up
Urination/Defecation issues
________________________
Is your pet currently taking any medications?
Yes
No
If so, name, dosage, how often, and last given:________________________________________
Is your pet allergic to any medications?
Yes
No _____________________________
Do you need a refill on any medications today?________________________________________
Extras:
Nail trim($16.00)
Dremel ($20.00)
Express anal glands ($26.00)
Ear cleaning($25.00)
May we sedate your pet if medically necessary? Yes No
Estimate of services $_____________________
Please call if treatment/testing is more than $ ______________ over estimate.
Authorization To Provide Care
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 .
Signature:_________________________________________________ Date:_______________
Phone: _______________________________________________________________________