Drop-Off Consent Form

Home Address *

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City

State

Zip Code

Country

Contact Number *

Additional Contact Number *

Phone Type *

Home Cell Phone

Phone Type *

Home Cell Phone Work

Email (requested) *

Pet Information

Reason for Visit (choose all that apply) *

Well Patient Exam/Update Vaccines Bath Professional Evaluation (sick/injured pet) Sedated Exam or Procedure

Patient History

Additional History - for Professional Evaluation (sick/injured pet)

Check ALL that apply (prices are approximations): *

Yes, I give consent to run blood work if needed. ($25-$200) Yes, I give consent for radiographs to be taken if needed. ($70/view) Yes, I give consent for testing other than blood work to be done if needed. (prices vary) NO, I would like to be called with a plan and an estimate after the initial examination is performed before giving consent for additional testing to be performed. By checking this box, I understand that no other diagnostics will be performed after the initial exam until a doctor is able to speak with me directly.

I understand that testing may be necessary to help my pet and that I must be readily available by phone to discuss the plan that is being recommended by the veterinarian working with my pet. I understand that I am responsible for payment for any services my pet receives at the time of discharge. *

I acknowledge that I have read the above statement.

Sedated Exam or Procedures

Please check all that apply *

Radiographs Ultrasound Sanitary Clip: Please list all areas to be clipped in the description box. Full-body Shave Down: Please list any areas you do NOT want to be shaved in the description box. Other: Please describe in the description box.

Please list/describe all scheduled sedated procedures to the best of your ability. *

Sedation Consent: I give consent to the doctors of Rowan Animal Clinic to administer sedation to my pet for the purpose of performing the afore mentioned procedure(s)/exam. I also acknowledge that there can be unavoidable risks associated with the administration of sedation. *

I understand and accept the risks of sedation.

Vaccination

Current vaccinations given by a licensed Veterinarian are essential for the protection of all animals in our care.

It is our policy that all dogs MUST be up-to-date on DHLP, Bordetella (Kennel Cough), and Rabies vaccinations when with us for an extended period.
It is our policy that all cats MUST be up-to-date on FVRCP and Rabies vaccinations when with us for an extended period.

If your pet was vaccinated at a clinic other than Rowan Animal Clinic, please e-mail or fax us updated vaccination records prior to your pets stay with us.

Flea and Tick Policy

Pets that arrive with fleas and/or ticks will be administered a treatment at an additional cost. We strive to protect our other guests and kennels from flea and tick infestation.

FLEAS: In the event that your pet is found to have fleas upon arrival, please choose an option for treatment. This comes at an additional cost. *

Please administer my pet a flea treatment that lasts for 24 hours. Please administer my pet a flea treatment that lasts for 30 days.

*Please Note*
In the event that your pet is found to have ticks upon arrival, the only treatment option available is a 30 day treatment.

Additional Services

*NOTE* If anything abnormal is found during the physical exam, the veterinarian will contact you prior to performing additional testing.

Medical Emergency Care Policy

*Please Note*
These services will come at an additional charge.
Pets are not directly monitored outside of normal business hours.

In the event that your pet has a medical emergency, Rowan Animal Clinic will begin emergency care and attempt to contact you at the emergency numbers that were given to us. *

I have read and acknowledge the above policy in regards to how Rowan Animal Clinic will proceed with care in the event that a medical emergency should occur.

Informed Consent

Informed Consent: I hereby authorize Rowan Animal Clinic to receive, prescribe for, treat, or operate upon my pet. I understand that by placing my pet in their care that I agree to allow them to use their best judgement in working with my pet. I understand that my pet will not be directly monitored outside of normal business hours and I assume responsibility for injury, loss, or destruction of my pet regardless of the circumstance. By checking the box below, I agree to pay in full for all services rendered and I understand that payment is dues immediately upon receipt of the invoice. *

I acknowledge that I have read the informed consent statement.

Drop-Off Consent Form

Client Information

Pet Information

Patient History

Additional History - for Professional Evaluation (sick/injured pet)

Sedated Exam or Procedures

Vaccination

Flea and Tick Policy

Additional Services

Medical Emergency Care Policy

Informed Consent

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