Drop Off Treatment Consent Form
North Star Animal Hospital
Teresa Beck, DVM - Shauna Henry, DVM - Mika Straub, DVM
For Office Use Only:
Information has been
entered into Medical
Condition:
Wt:
Owner’s Name:
Patient’s Name:
Species:
Gender:
Breed:
Fixed: Y N
Age:
Color:
Birthday:
Reason for today's visit: ______________________________________________________________________
Has your pet had any medication today? Y
N If so, please list:
Is your pet allergic to any medications?
N If so, please list:
Y
Other allergies: _____________________________________________________________________________
Is your pet eating normally?
Y
N If so, please list what: _______________________________
Any diet changes? (treats, scraps, etc)
Y
N Describe:
Is your pet drinking normally?
Y
N
Any bowel movements today?
Y
N Was stool normal?
Y
N
Y
N Was urine normal?
Y
N
If abnormal, for how long?
Has your pet urinated today?
If abnormal, for how long?
Recent Surgery
Y
N
Describe: ____________________________________
Vomiting
Y
N
How long? ___________________________________
Lethargy (Lack of Energy)
Y
N
How long? ___________________________________
Limping?
Y
N
How long? ______________Which leg?
Coughing/Gagging
Y
N
How long? ___________________________________
Sneezing
Y
N
How long? ___________________________________
Scratching
Y
N
Where? ______________________________________
Seizures
Y
N
Last occurrence: _______________________________
New Lumps/Bumps
Y
N
Where/How long? _____________________________
Bad Breath
Y
N
How Long? __________________________________
Weight gain/loss
Y
N
How much/when? _____________________________
Behavioral changes
Y
N
Describe: ____________________________________
Other comments or concerns: __________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I, the undersigned owner or authorized agent of the above pet, certify that I am eighteen years of age or over. I consent to
the treatment of my pet by staff veterinarians at North Star Animal Hospital. I also agree that the hospital's doctors may
prescribe medication for, treat, hospitalize, anesthetize and/or perform surgery on my pet. Should some unexpected lifesaving emergency care be required and the attending veterinarian is unable to reach me, the hospital staff has my permission
to provide such treatment, and I agree to pay for such care.
I agree to assume financial responsibility to all fees accrued during my pet's treatment. In the event that my pet is
hospitalized for more than 24 hours and the attending doctor is unable to reach me, I understand it is my responsibility to
call the hospital every 24 hours to inquire as to the medical status of my pet and the fees incurred for medical services up to
that day.
I authorize pain relief or sedation for examination or treatment today if necessary:
Yes
No
Call 1st
Owner's Signature:________________________________________________ Date:_____________________
The telephone number(s) where we can reach you today: ____________________________________________