First Name (required)
Last Name (required)
Pets Name (required)
When was the last time your pet ate?
What diet do you feed your pet?
Did you bring their food?
What type of insulin are you administering?
What dose are you giving (how many units and how often)?
Dosage of Insulin:
Did you bring your pet's insulin with you today?
Did you leave any personal items with your pet today? If so please list them.
Is your pet vomiting, having diarrhea, coughing, sneezing, feeling lethargic or not eating?
If so, please describe the frequency of the problem and when it began.
What medication(s) your pet is taking, how much and how often?
Please list any questions / concerns you have or procedures you are interested in while your pet is here (ie. Nail trim, vaccines, snap test, dental cleaning, grooming).
Questions or Concerns:
Did you leave any personal items with your pet today? If so please list them:
Please leave a reliable phone number and/or the name and number of another person who will be responsible for making decisions regarding your pet, that can be directly contacted today. Please leave as many numbers and contacts as possible.
Please understand that during the course of your pet's stay with us unforeseen conditions may arise that necessitate medical attention from our staff. If we are unable to reach you or your representative at any of the above numbers provided your signature here authorized the performance of such procedures as are deemed necessary by the veterinarian's professional judgment.
Veterinary service during nighttime hours, some daytime hours and/or weekends, is provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not be provided during these hours. (California Code of Regulations Title 16 Section 2030).
All accounts are to be paid in full at time of pick up. If you, the owner are not the one picking up your pet, do you authorize someone to do so?
If this person is not financially responsible for your pet, please arrange for payment ahead of time.
An outpatient fee is assessed for all patients being dropped off for medical services. Thank You.