Existing Client/ Drop Off Form – Atlas Pet Hospital

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Existing Client/ Drop off Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Owner's Name
Name*
First Last
Primary Phone*
Secondary Phone
Email*
Enter Email Confirm Email
Are you the person picking up your pet ?*
- Yes
- No
Name of Authorized Person
First Last
Phone of Authorized
Pet #1 Information
Pet #1 Name:*
Species #1*
Breed #1*
Sex #1*
Is your pet #1 up to date with the Vaccines ?*
- Yes
- No
- Unkown
Is your pet #1 on any medication? Does the pet have allergies or Drug reactions?
Please describe briefly if Yes.
- Yes
- No
If Yes, please describe it briefly
Reason for visit Pet 1:*
- Puppy/Kitten Plan
- Adult Plan
- Preventive Care
- Surgery
- Vomiting/ Diarrhea
- Coughing/ Sneezing
- Weight Gain/Weight Loss
- Itching / Scratching
- Bad Breath
- Urinating Issues
- Bowel Movement Issues
- Walking Issue
- Ear/Eye/Nose
- Other
If other please describe briefly the reason for the visit:*
If Weight Gain or Loss, please explain more in details:*
If Walking Issues, please explain more in details:*
If Eye/Ear/Nose, please explain more in details:*
If Itching/Scratching, please explain more in details:*
If Bowel Movement Issues, please explain more in details:*
If Vomiting/Diarrhea please explain in details:*
If Coughing/Sneezing please explain your concern:*
If Urinating Issues, please explain more in details:*
If Surgery please specify the surgery type:*
Do you have another Pet to Drop Off?*
- No
- Yes
Pet # 2 Information
Pet #2 Name
Species #2
Breed #2*
Sex #2
Is your pet #2 up to date with the Vaccines ?
- Yes
- No
- Unkown
Is your pet #2 on any medication? Does the pet have allergies or Drug reactions?
Please describe briefly if Yes.
- Yes
- No
If Yes, please describe it briefly
Reason for visit Pet 2:*
- Puppy/Kitten Plan
- Adult Plan
- Preventive Care
- Surgery
- Vomiting/ Diarrhea
- Coughing/ Sneezing
- Weight Gain/Weight Loss
- Itching / Scratching
- Bad Breath
- Urinating Issues
- Bowel Movement Issues
- Walking Issue
- Ear/Eye/Nose
- Other
If Eye/Ear/Nose, please explain more in details:*
If other please describe briefly the reason for the visit:*
If Walking Issues, please explain more in details:*
If Weight Gain or Loss, please explain more in details:*
If Itching/Scratching, please explain more in details:*
If Surgery please specify the surgery type:*
If Urinating Issues, please explain more in details:*
If Coughing/Sneezing please explain your concern:*
If Vomiting/Diarrhea please explain in details:*
By checking this box I agree to the following terms:*
- I am the owner (or authorized agent of the owner of the pet(s) mentioned above), I hereby authorize Atlas Pet Hospital to perform services, procedures, diagnostics, vaccinations, treatments, and administration of extra label medications as deemed necessary or advisable in connection with the concerns mentioned above or the matters that have otherwise been explained by the Atlas Pet Hospital staff. I understand that there is a risk of complications with every procedure, including the possibility of death as a severe complication of surgery, anesthesia, or other procedures. I also understand that there is no guarantee as to the results of any procedures, diagnostics, vaccinations, or treatments. I understand that I may ask any questions that I have regarding any procedure, diagnostic, vaccination, or treatment recommended by the veterinarian before it is performed. I authorize Atlas Pet Hospital to administer Capstar Tablet ($13.50) if my pet is diagnosed with fleas during his/her visit.

Ready to see our veterinary team? Schedule Appointment

DIRECTIONS

CONTACT INFORMATION

1560 Hamner Ave.
Norco, CA 92860

Phone: 951-737-1242
Fax: 951-549-9056
Email: [email protected]

HOURS OF OPERATION

Monday-Saturday: 8:00AM-8:00PM
Sunday: CLOSED

New Year’s Eve:
12/31/2020: 8:00AM-5:00PM

New Year Day:
1/1/2021: 10:00AM-6:00PM

**For emergencies after hours, please call our main line and we will provide you instructions on how to handle the situation.

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Clients Form
About Us
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