Name* First Last Pet Name*Breed*Color*VertinarianDr. Tania White, DVMDr. Susan Sanchez, DVMUnsureAppointment Time* : HH MM AM PM Reason for today's visit*Phone Number to best reach you*Vehicle Make/Model/Color*Do you have the HPVC app? Our app is best way to ensure you are able to see all communications and pet reminders. It also allows requesting appointments, medications, and medical records.*YesNoWhat time are you available to pick up your pet today? Expect pick-up no later than 4:30 pm, closing time* : HH MM AM PM Is your pet currently taking any medications, vitamins, supplements?* Frequency and dosages of all medications taken in last 24hrsPlease select any other treatments you would like your pet to receive: Microchip Nail Trim Update Vaccines Bloodwork Prescription refill Anal glands Flea Medication Fecal test Other Other treatment*In order to allow for diagnostics/treatments to be started, we require a minimum monetary allowance when a patient is being dropped off: $200 for wellness/vaccine visit, diarrhea cases, itching cases, and/or ear infection $250 for inappropriate urinating and/or suspect urinary tract infections $400 for patient who are vomiting, limping, and/or inappetent (X-rays are expected) X-rays alone are $250 + exam (65) = $315 If in the unlikely event that life saving measures need to be taken while my pet is under the care of HPVC:*I DO want any/all measure performed to save my petI do NOT want heroic measures taken to save my petHeroic measures may include oxygen treatment, IV fluids, addition medications, and/or CPR. Additional fees of at least $150 will be charged if this is necessary. Again, in the rare event these measures are needed, we will contact you as soon as the pet is stable. Please read: We close at 4:30p. We are in a residential area and cannot board pets overnight. Please make arrangements for your pet to be picked up before closing. There is no staff on premise overnight. Fees/Payment - It is understood that I shall be responsible for the costs in connection with any care and/or medical treatment related to the above issue and that payment shall be made in full, prior to the return of my pet to my care. I understand that any estimate of fees given for a trement plan are just that, an estimate, and that the cost to treat my pet may exceed expected treatment plants. I certify that the above information is correct, and I understand that the information. By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully. Name* First Last Date* Date Format: MM slash DD slash YYYY Time* : HH MM AM PM Signature*