Briarcliff Animal Clinic Too
Drop-Off Release
Please check any problems that you wish to be addressed today:
[ ] Vomiting
[ ] Itching
[ ] Ear Problem
[ ] Difficulty Urinating
[ ] Diarrhea
[ ] Rash
[ ] Eye Problem
[ ] Difficulty Defecating
[ ] Coughing
[ ] Hair Loss
[ ] Tooth/Mouth Problem
[ ] Increased Appetite
[ ] Fleas
[ ] Licking Feet
[ ] Behavioral Problem
[ ] Decreased Appetite
[ ] Cut/Abscess
[ ] Sneezing
[ ] Excessive Thirst
[ ] Weight Loss
[ ] Painful Area(s)
[ ] Limping/Lameness
[ ] Excessive Urination
[ ] Weight Gain
Please describe any of the above problems or additional problems:
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Does your pet visit:
[ ] Wooded Areas
[ ] Dog Parks
[ ] Mountain House
[ ] Farms
[ ] Lake House
[ ] Other (if relevant)________________________
Is your pet on any medications (including flea/tick/heartworm products)?
[ ] Yes
[ ] No
If yes, please list name of medication(s), frequency and dose:
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What brand food do you feed your pet and consistency (wet or dry)?
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Is your pet strictly: [ ] Indoor
[ ] Outdoor
Which of the following applies to your pet?
[ ] Both
[ ] Leash walked
[ ] Fenced Yard
[ ] Never goes outside
Do you have other pets?
[ ] Cat(s)
[ ] Dog(s)
[ ] Invisible Fence
[ ] Occasionally goes outside
[ ] Other __________________
Does your pet have any known allergies (to food, medication, vaccines, etc.)?
[ ] Yes
[ ] No
If yes, please describe:
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Do you need a refill on any medications today (heartworm/flea prevention or others)?
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(PLEASE CONTINUE TO THE REVERSE SIDE OF THIS PAGE)
By dropping off my pet for treatment, I agree to a Physical Exam by a doctor for a fee of $57.75.
I certify that all information on this form is complete and accurate to the best of my knowledge, and I
release Briarcliff Animal Clinic of any liability arising in whole or in part from any information that is
not correct.
I understand that if proof of a current rabies vaccine is not available, Briarcliff Animal Clinic will vaccinate
my pet against Rabies. Briarcliff Animal Clinic will not examine or treat a pet that is not current on Rabies
vaccination.
SIGNATURE__________________________________________ DATE_____________
**Please leave a phone number where you can be reached in order for the doctor to discuss the treatment
plan and provide an estimate for any additional diagnostics or treatment.
I can be reached at (
) ______-_________ or (
)_______-___________
Boarding/Well Drop Off:
Canine
[ ] Rabies
[ ] DAPP
[ ] Bordetella
[ ] Lepto
[ ] Fecal
[ ] Heartworm Test
[ ] Bath
[ ] Clip Nails
[ ] Express Anal Glands
[ ] Ear Cleaning
[ ] Physical Exam
[ ] ProHeart 6 Injection
Feline
[ ] Rabies
[ ] HCP
[ ] FeLV
[ ] Fecal
[ ] Clip Nails
[ ] Physical Exam
[ ] Bath