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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
*
Dog
Cat
Breed #1
*
Sex #1
*
Neutered Male
Spayed Female
Male
Female
Unknown
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
Dog
Cat
Breed #2
*
Sex #2
Neutered Male
Spayed Female
Male
Female
Unknown
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.
Clients Form
New Client/ Drop Off Form
Existing Client/ Drop Off Form
Anesthesia / Surgical/ Sedation Consent Form
Grooming Release Form
Boarding Form
What To Expect
Take A Tour
Payment Options
About Us
Location & Hours
Our Team
Employment Opportunities
Specials
Make an Appointment
Promotions
Testimonials
Pet Services
Medical Services
Preventive Services
Surgical Services
Wellness and Vaccination Programs
My Pet
Profile
My Pet’s Medical Records
Request Services
Feedback
Pet Health
Interactive Animal
Breed Info
Videos
Pet Health Checker
News
Links