Drop Off Form Client/Patient InfoClient Name:* First Last Email:* Patient Name:* First Last Date:* What do you need performed on your pet today?* Exam Vaccines Boarding BathPatient ProblemsPlease check the significant problems that apply to your pet:* Coughing Sneezing Itching skin Scratching Ears Eye Discharge Nose Discharge Lethargic Losing Weight Vomiting Limping Difficulty Defecating Having Seizures OtherIf other, please list the problem:*How long has your pet displayed these problems?*Has your pet had any previous problems?*Eating and Drinking HabitsDescribe your pet's eating habits:*NormalIncreasedDecreasedWhat are you currently feeding your pet?*Dry foodCanned foodPeople foodWhat brand?*Is this a recent change?* Yes NoIf yes, what were you previously feeding?*Describe your pet's drinking habits:*NormalIncreasedDecreasedUrine/Bowel HabitsDescribe your pet's urine habits:*NormalIncreasedDecreasedDescribe your pet's bowel habits:*NormalSoftDiarrheaIf Diarrhea:*Small AmountLarge AmountBloodOther Patient InfoIf your pet has lumps, bumps, cuts, sores that you wish to have us look at please describe the location.Where does your pet spend his/her time?*Only indoor (never outside)Equally indoor/outdoorMainly indoorMainly outdoorIs your pet currently receiving any other medications? Please list medications and daily dose.Other Client InfoPlease list any other comments or questions you have for the doctor:In order to diagnose your pet's condition, your pet may require blood tests, xrays, and/or other diagnostic testing. Do you authorize tests if the doctor feels it is warranted?*Do what is necessaryCall with estimate prior to any treatmentPlease select any additional services that you would like performed while your pet is in the hospital: Nail Trim Anal Gland Expression BathIt is very important that the doctor is able to contact you if he/she has questions regarding your pet. Failure to be reached may result in postponement of treatment.Primary number you can be reached today:*Alternate number:Drop off exams are offered for your convenience. Your pet will be examined when the doctor's schedule allows. (Critical patients will be examined immediately). Pick up times cannot be guaranteed. There is a $5 fee for drop offs (excluding boarding/baths).By pressing the submit button, I, the owner of the above pet, authorize Mountain View Animal Hospital & Holistic Pet Care to exam, diagnose, and treat my pet as approved above.