Clients’ Name (Owner) *

Date *

Best Number You Can Be Reached At Today: *

Are you ok to receive text message communications at this number? *

Yes
No

Email *

Pet's Name *

Age *

Sex *

Altered (Spayed/Neutered) *

Yes
No

Is your pet: *

Indoor
Outdoor
Indoor/Outdoor

Last Time Your Pet Ate *

Brand of Food *

Table Scraps *

Have you given your pet any medications, prescribed or over the counter in the last 48 hours? *

Yes
No

(If yes please list below)

If medication has been given, please list the name of medication, dose, and time: *

Medications Given: *

Does your pet have any known allergies? *

Do you give your pet any flea, tick, and/or deworming treatments? *

Yes
No

Please list the last date and name of product given: *

If yes, what product(s) do you use: *

Please explain the reason for today’s visit. Please be as specific as possible. *

Please check any of the following signs below that your pet is exhibiting and indicate how often they occur/when they started showing symptoms.

Please provide symptom details: *

Additional Details: *

ex. How often? When did it start?

Where from? *

Location of Lumps/Bumps? *

Which leg? *

Please list any previous illnesses or medical history:

Do we have your permission to sedate your pet if needed? (for adequate exams or treatment) *

Yes
No

After the examination, the veterinarian may want to proceed with other diagnostic test (i.e. X-rays, bloodwork, etc). Do we have your permission to do so? *

Yes
No, please call first

What amount are you willing to spend without an estimate?

Note: If blood work +/- x-rays are needed an estimated range is $300-500.

***Amount willing to spend without an estimate *

OWNER RELEASE

I understand that payment is due in full at the time of discharge for all services rendered and deemed necessary, regardless of whether the circumstances are medical, surgical, foreseen, or unforeseen. (Payments need to be in Cash, Card, or Cherry Payment Plan. Checks are not accepted.)
If you have financial concerns, please ask one of our staff members about Cherry Payment Plan payment options.
I understand that if my pet is found to have parasites (external or internal), he/she will be treated at my expense.
I have the right to an estimate, and the staff at Snake River Veterinary Center will make every attempt to notify me of medical changes and updates related to my pet's care.
I do certify that I am the owner or authorized agent of the above-described animal and have the right to make any and all medical decisions in his/her case.
I understand that Snake River Veterinary Center will use all reasonable precautions against escape, injury, and death. I will not hold Snake River Veterinary Center or the staff liable for any problems that develop, provided the above precautions are followed.
I understand that all surgical and anesthetic procedures have risks. Snake River Veterinary Center will provide the highest level of medicine to minimize these risks. I release Snake River Veterinary Center and staff of any and all responsibility and liability in the absence of gross negligence.

SNAKE RIVER VETERINARY CENTER DOES NOT BILL

Signature *

Clear Signature

Date *

Drop-Off Form

How to Complete the Form

Drop-Off Form

OWNER RELEASE

SNAKE RIVER VETERINARY CENTER DOES NOT BILL

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