"*" indicates required fields Name* First Last Pet name* Breed* Phone Number to best reach you*Vehicle Make/Model/Color Does your pet have any health concerns or behavior issues we should be aware of?* Yes No If so, please note*Is your pet on any medications?* Yes No If so, please note*Do you have our phone app?* Yes No If no, please download our free app. We are going to do our best to ensure we are communicating through the app during your appointment. If yes, please ensure your notifications are on to ensure you are receiving our updates throughout the day. Your appointment was set as follows* Drop off by 9:30 am, so you may pick up AFTER 12pm Drop off by 10:30 am, so you may pick up AFTER 2 pm Drop off by 12pm, so you may pick up around closing time, shortly before 4:30pm At what time are you available to pick up your pet today?* Please select any other treatments you would like your pet to receive: Microchip $82.03 Nail Trim Vaccines Bloodwork Anal Gland Expression Flea Treatment If it becomes necessary, do you approve the use of a mild sedative?* Yes No ***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 and NAD, that would start at 279 (80+199). If mild sedation is necessary, that would be about an additional $49. This would bring your new total to $328. Call if over: $* 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 measures performed to save my pet. I do NOT want heroic measures taken to save my pet Heroic 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. Please call AFTER 3pm to check on the status of your pet. We close at 4:30pm on weekdays. We are closed on the weekend. If your pet has been ready to go and they're not picked up by 4:45pm, an additional charge of $25 will be applied for the late pickup fee. 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 treatment plan are just that, an estimate, and that the cost to treat my pet may exceed expected treatment plans. Signature*Checked in by: Date* MM slash DD slash YYYY
