Client Name(Required) First Last Pet's Name(Required) Contact NumberDrop-off reason Wellness Illness Other If Other, Explain WellnessCanine Rabies Bordetella Intestinal Parasite Screen Distemper/Parvo HW Test Feline Rabies Leukemia Intestinal Parasite Screen Distemper FIV/FELV Test Do you need more heartworm/flea prevention today? Yes No If yes, how many months’ worth? What kind? IllnessPlease describe your concerns about your pet.ServicesWhile your pet is with us, would you like any of the following services performed? Nail trim Ear Cleaning Anal gland expression Other If Other, Explain What to ExpectWhat to Expect: Your pet will receive a comprehensive physical exam by one of our Veterinarians. In most cases, diagnostic tests will be needed to fully determine the cause of your pet’s illness. Our team will attempt to contact you to discuss any needed diagnostic testing and provide a treatment plan. In the event that you cannot be reached, please note your wishes below:(Required) I authorize a maximum amount for diagnostic testing and necessary medications. I do not authorize any diagnostic testing or services without prior consultation. Maximum amount of $(Required) Signature(Required) (Your digital signature (full name) is as legally binding as a physical signature.) Date MM slash DD slash YYYY
