Drop Off Form

Owner Details

Pet Details

Sex

PRIMARY COMPLAINTS:

Vomiting, Diarrhea, Blood in Stool
Itching, Hair loss, Skin Sores
Coughing, Sneezing, Difficulty Breathing
Blood in Urine, Difficulty Urinating, Urinary Incontinence
Eye problems, Ear problems
Painful, Lethargic
Changes in drinking or eating
Was your pet fed today?
Is your pet current on vaccinations?
Is your pet on heartworm/flea and tick medication?

Please read and check the following:

If doctor recommended, we may need to preform lab work depending on symptoms.
If doctor recommended, we need to preform diagnostic testing, such as x-rays.

Please read and sign the following

I hereby give my consent to Trident Veterinary Hospital to perform an exam and treatment(s). I understand that I will be responsible for any and all charges associated with these treatments at the time I pick up my pet.
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PLEASE CHOOSE ONLY ONE TO AUTHORIZE

In the event of cardiopulmonary arrest (loss of heartbeat and breathing), I understand that I will be contacted to discuss options of care. Until I can be reached, I authorize the following (PLEASE SELECT ONE):

As the owner (or authorized agent for the owner) of <animal>, I do hereby consent and grant the veterinarian(s) of Trident Veterinary Hospital and all of their employees, agents, servants, and/or representatives (collectively, the “Hospital”) full and complete authority to perform the procedures and treatments described above and to perform any other procedure or treatment that, at the attending veterinarian’s discretion, may be deemed medically necessary for <animal>, and I do hereby forever release and discharge the Hospital from any and all liability arising from such procedures and treatments.

I understand that all fees associated with the above authorized care are expected to be paid in full at that time of pick-up. 

I do hereby consent and agree that photographs and digital recordings of my pet brained during hospitalization may be used for the purpose of medical case reports, education presentations and advertising purposes.  Client confidentiality will be maintained 
 

I accept and agree to the terms above

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