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Appointment Request
Home
About Us ▼
About Us
Standards of Care
Meet Our Team
>
Our Veterinarians
Our Care Team
Meet our Staff Pets
Holiday Hours
Reviews
Take a Tour
Dog Park
Community Support
Services ▼
Boarding
New Pet
>
New Kitten
New Puppy
Small Animal Services
Production Animal Services
Online Store
Resources ▼
Online Forms
>
New Client Form
New Pet Form
Surgical Consent Form
Boarding Consent Form
Drop-Off Consent Form
Emergency
Financial Assistance Organizations
Parasites
>
Fleas
Heartworms
Ticks
Surgical FAQS
Discharge Instructions
Drugs / Diseases / Surgical Procedures
Helpful Links
Pet Insurance
Pet Records
Seasonal Pet Care
Contact Us ▼
Appointment Request
Drop-Off Consent Form
Client Information
*
Indicates required field
Client Name
*
First
Last
Home Address
*
Line 1
Line 2
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
Pet Name
*
D.O.B. or Approximate Age
*
Sex
*
Male
Neutered Male
Female
Spayed Female
Pet Breed
*
Color/Markings
*
Reason for Visit (choose all that apply)
*
Well Patient Exam/Update Vaccines
Bath
Professional Evaluation (sick/injured pet)
Sedated Exam or Procedure
Patient History
Is your pet eating and drinking normally?
*
Yes
No
If you checked NO, please explain:
*
Is your pet urinating and defecating normally?
*
Yes
No
If you checked NO, please explain:
*
What is your pets' normal diet, including treats and other extras?
*
Do you have any concerns or questions about your pet? If so, please complete the box below.
*
Additional History - for Professional Evaluation (sick/injured pet)
What is your pets major presenting problem and what is its' duration?
*
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.
Choose ALL services requested (come at additional cost):
*
Annual Physical Exam - Because of the shorter lifespan of our pets, allowing the veterinarian to perform a physical exam every year is the smartest and easiest way to keep them healthy. Exams allow the veterinarian to detect problems before they become severe or costly.
DHLP or DHPP vaccine (canine)
Bordetella Vaccine (canine)
Rabies Vaccine
FVRCP Vaccine (feline)
Leukemia Vaccine (feline)
Nail Trim
Anal Glands Expression
Sanitary Trim - Please list areas to be trimmed in comment box below
Heartworm Check (canine)
Intestinal Parasite Check - Please bring a fresh stool sample
Wellness Bloodwork Screening - Recommended annually on all healthy pets to establish a baseline for overall organ function. This will also help the veterinarian catch potential problems earlier as your pet ages.
FeLV/FIV Screening - Recommended for new or sick cats that have not previously been tested.
Microchip - Fee includes implantation and lifetime registration.
Can we get you any Flea, Tick, and/or Heartworm preventative? If so, please check the appropriate boxes.
*
Comfortis - Fleas only
Simparica - Fleas and Ticks (Dogs Only)
Frontline Gold - Fleas and Ticks (Cats Only)
Trifexis - Heartworms and Fleas (Dogs Only)
Interceptor - Heartworms (Dogs only)
*NOTE*
We have rebates available when purchasing 6 or 12 doses of preventative.
If requesting flea, tick, and/or heartworm preventatives, please list the quantity requested below.
*
Additional information or comments:
*
Medical Emergency Care Policy
*Please Note*
These services will come at an additional charge.
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 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.
Submit
