Name* First Last Pet name*Breed*Phone Number to best reach you*Vehicle Make/Model/ColorDoes your pet have any health concerns or behavior issues we should be aware of?*Are they currently on any medication or supplements? If so, which medication and how often is it given?*Do you need any medication refills?Do you have our phone app? If, no please download as moving forward we are going to do our best to ensure we are communicating through the app. If yes, please ensure your notifications are on to ensure you are receiving our updates throughout the day*YesNoYour appointment was set as follows*Drop off by 9:30 am, so you may pick up AFTER 12pmDrop off by 10:30 am, so you may pick up AFTER 2 pmDrop off by 12pm, pick up by 4pmAt what time are you available to pick up your pet today?*Please select any other treatments you would like your pet to receive Microchip Nail trim Anal gland expression Update vaccines Labwork Flea treatment If it becomes necessary, do you approve the use of a mild sedative?*YesNo**If sedation is deemed necessary, your pet will need to stay with us until the end of the day to allow for us to monitor him/her until full recovery is achieved.**By dropping off, you authorize the doctor to treat as deemed necessary. Is there a monetary amount you do not want to exceed? If here for Exam & NAD, that would start at &245 (65+180). If sedation is necessary, that would be an additional $72. This would bring your new total to $317. Call if over*PDN alone is $180If 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 measures performed to save my petI do NOT want heroic measures taken to save my petHeroic measures may include oxygen treatment, iv fluids, additional medications, and CPR. Additional fees of at least $150 will be charged if this is necessary. During the procedure we may find loose, broken or decayed teeth that may need to be removed. This can only be done under full anesthesia. If this occurs, we will schedule your pet for a full anesthetic dental in the near future. Post Care may include antibiotics and/or home care products.Signature*
