medicalreleaseDrop Off Form Download Date Date Format: MM slash DD slash YYYY We will need to be able to contact you or someone with permission to make medical and financial decisions.Who will we be speaking with? Name*1st Phone #*2nd Phone #Reason for Visit: (check all that apply)EXAM: Annual Wellness Illness/Injury (describe below) Recheck For Surgery For Dental Medication Refill OTHER SERVICES: Bandage change Radiographs Labwork Ultrasound CT Scan Other (describe below) Illness/InjuryOtherAre there any concerns for: (check all that apply) Eating Weight gain Vomiting Coughing Drinking Itching/scratching Diarrhea Sneezing Bad Breath Difficulty rising Skin masses/lesions Lethargic Excessive Sleeping Scooting Urination issues Weight loss Shaking head Behavioral problems Other OtherWhen did the problem(s) start?ExplainWhen did your pet last eat/drink?* Date Format: MM slash DD slash YYYY Approximate Time* : HH MM AM PM Any allergies to any food or medications?*YesNoIf yes, explainCurrent medicationsMedication nameAmount givenFrequencyLast givenNext dueMedication nameAmount givenFrequencyLast givenNext dueMedication nameAmount givenFrequencyLast givenNext dueMedication nameAmount givenFrequencyLast givenNext dueAre you leaving medications with your pet today?*YesNoDoes your pet have any chronic medical conditions? Or previous surgeries?If yes, explain:Would you like your pet to receive any routine services?(check all that apply) Update vaccines Ear cleaning Heartworm tests---- Refills needed (Yes) Nail trim Fecal analysis Flea medication---- Refills needed (Yes) Microchip Anal gland expression Deworming Other medication refills needed? Prescription Name(s)Any history of vaccine reactions in the past?*YesNoAdditional questions or concernsAppointment Date and Time (if already scheduled):Appointment Date Date Format: MM slash DD slash YYYY Appointment Time : HH MM AM PM Please be advised, the veterinarian will first examine your pet then call you to get authorization of an itemized treatment plan PRIOR to doing any procedures/treatments on your pet. If urgent care becomes necessary for the health of your pet while at Western Veterinary Group, I understand the staff will make every effort to contact me, as time allows. If I cannot be contacted, I authorize any and all urgent treatments as determined by the veterinarian. I understand that payment must be made in full at time of pick up, and am aware that WVG accepts cash, credit cards, and Care Credit.Signature*Date Date Format: MM slash DD slash YYYY
