Release for treatment:

By submitting the form below, you understand the doctor will be examining your pet today and that there will be an associated EXAM CHARGE for today's visit.

Form - Drop-Off/Check-in

Date (required)

Owner's Full Name & Pet's Name (required)
First Name (required)
Last Name (required)
Pet's Name (required)

Problem Area
What is the problem?

When did it begin?

How has it changed since it started?

Is there anything else you would like the doctor to know?

Contact Information & Pickup Arrangements
What is a good number to reach you at today? (required)

What time would you like to pick your pet up today? (required)

Contact me before initiating treatment and incurring additional charges.

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