Patient Drop-Off Release Form

Skyview Animal Clinic

Patient Drop-Off Release Form

Pet’s Name ______Pet’s Age ______Date ______

Reason for Visit: (Please briefly explain)

______

______

Please check and describe any and all symptoms that your pet is showing.

Gastrointestinal Symptoms (Vomiting, Diarrhea, “Tummy” Troubles):

□  Vomiting/Heaving: Duration: ______#times/day: ______Last occurrence______

o  Vomited (please circle) Food Phlegm Bile Unknown Foreign Object ______

□  Diarrhea/Soft Stool: Duration: ______#times/day: ______

o  Stool contained (please circle) Mucus Blood Intestinal Worms Unknown

o  Stool Color: ______

□  Scooting

Dermatologic Symptoms (Skin Issues):

□  Scratching/Itchy Skin: Duration: ______Part of body? ______

□  Redness

□  Flakiness

□  Ear Problems: Left Right Both Discharge from ears? ______Odor? ______

□  Shaking Head

□  Eye Problems: Left Right Both Description:______Discharge? ______

□  Unusual Lumps or Bumps: First noticed?:______Part of Body: ______

Specific Location (please circle): Right Side Left Side Ventral (belly) Dorsal (back)

Urinary Symptoms

□  Straining to Urinate

□  Decrease/Increase in Urination: Duration: ______#times/day: ______

□  Inappropriate Urination – Urinating Outside Litter Box or Accidents: Duration: ______

Are there any of the following present in the urine?

Blood Odor Cloudiness Other ______

Other Symptoms (Joint Issues, Behavioral, Lethargy, Etc.)

□  Coughing: Duration: ______Productive? If yes, description______

□  Sneezing: Duration: ______Discharge? If yes, description______

□  Weight Loss/Gain (please circle) Duration: ______

□  Change in Appetite: Increase? Decrease? Duration:______

□  Change in Water Intake: Increase? Decrease? Duration: ______

□  Weakness/Inability to Walk: Duration: ______

□  Behavioral Changes: Please describe: ______

______

□  Limping: Duration: ______Which leg(s)?: ______

□  Lethargy/Listlessness: Duration: ______

Additional Comments:______

______

If deemed medically necessary by the doctor, I authorize the following care for my pet:

Diagnostic Blood work ($40-$110) □ Yes □ No

Urinalysis and Sedimentation ($20) □ Yes □ No

Radiographs (x-rays) ($90-$140) □ Yes □ No

Sedation ($20-$50) □ Yes □ No

Heartworm Test ($28) □ Yes □ No

Intestinal Parasite Test ($10) □ Yes □ No

Feline Leukemia/FIV Test ($37) □ Yes □ No

All pets dropped off will be seen after scheduled appointments and surgeries. Normal pick-up time for pets that are dropped off is between 4:30pm-5:30pm. A staff member will contact you when your pet is ready for pick-up. You may call at any time to check on his/her progress.

Signature: ______Date: ______