medicalreleaseDrop Off Form Download Date 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/Injury Other Are 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 Other When did the problem(s) start? ExplainWhen did your pet last eat/drink?* MM slash DD slash YYYY Approximate Time* : Hours Minutes AM PM Any allergies to any food or medications?* Yes No If yes, explainCurrent medicationsMedication name Amount given Frequency Last given Next due Medication name Amount given Frequency Last given Next due Medication name Amount given Frequency Last given Next due Medication name Amount given Frequency Last given Next due Are you leaving medications with your pet today?* Yes No Does 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?* Yes No Additional questions or concernsAppointment Date and Time (if already scheduled):Appointment Date MM slash DD slash YYYY Appointment Time : Hours Minutes 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 MM slash DD slash YYYY
