Existing Client/ Drop Off Request Owner's NameName* First Last Row StartPrimary Phone*Column BreakSecondary PhoneColumn BreakEmail* Row EndRow StartAre you the person picking up your pet ?* Yes No Column BreakPhone of Authorized*Row EndName of Authorized Person* First Last Pet #1 InformationRow StartPet #1 Name:* Column BreakSpecies #1*DogCatRow EndRow StartBreed #1* Column BreakSex #1*Neutered MaleSpayed FemaleMaleFemaleUnknownRow EndRow StartIs your pet #1 up to date with the Vaccines ?* Yes No Unkown Column BreakIs your pet #1 on any medication? Does the pet have allergies or Drug reactions?Please describe briefly if Yes. Yes No Row EndIf Yes, please describe it brieflyReason 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 InformationRow StartPet #2 Name Column BreakSpecies #2DogCatColumn BreakBreed #2* Column BreakSex #2Neutered MaleSpayed FemaleMaleFemaleUnknownRow EndRow StartIs your pet #2 up to date with the Vaccines ? Yes No Unkown Column BreakIs your pet #2 on any medication? Does the pet have allergies or Drug reactions?Please describe briefly if Yes. Yes No Row EndIf Yes, please describe it brieflyReason 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.
