Berryhill Animal Hospital

Drop-off Form

Berryhill Animal Hospital
Drop-off Patient Consent for Treatment Form
Forms need to be completed 24 hours prior to services unless otherwise directed. You will be contacted via telephone or e-mail regarding confirmation of your appointment request.

* Required Fields

Name^*
Address^*
City^*	State^* Zip^*
E-Mail^*
Home Phone^*	Cell
Pet's Name^*
Expected Arrival Date^* Expected Arrival Time^*

Routine Services
(Please check all services to be performed)

Canine Vaccinations
Rabies
Distemper
Bordetella-6 months

Feline Vaccinations
Rabies
Feline Distemper
Feline Leukemia

Diagnostic Tests
Physical Exam
Intestinal Parasite Exam/Fecal Flotation
Heartworm Test (Dogs)
Feline Leukemia/FIV Test (Cats ONLY)
Blood Screening Profile
Senior Blood Work (7 years or older)
Spa Services
General Bath (includes nail trim/ear cleaning/anal glands expressed)
Medicated Bath (as determined by Doctor)
Grooming (Appointment with Pat at VIP Grooming here at Berryhill)
Nail Trim Only

Medical
Primary Complaint(s):
(Please check all that apply)
Vomiting Diarrhea Blood in Stool Not Eating Losing Weight Coughing Sneezing
Difficulty Breathing Lameness/Limping Itching Hair Loss Ear Problem Eye Problem
Lethargic/Depressed Urinating Frequently Straining to Urinate Blood in Urine Bite Wound
Abnormal Behavior Check a Growth or Tumor Ate or Swallowed Foreign Object Pain
Other

Specify Complaint(s): (Such as: left leg, growth on face, at a bone, hiding, etc.)

Duration of Condition(s): (Such as: hours, days, weeks, etc.)

What medications (if any) has your pet received in the last 24 hours?

Name of Medication	Amount Given	What Time
1.
2.
3.
4.

Please use the following box to provide any other information we might need
to know about your pet(s) and any special needs or dietary requirements.

Would you like us to:
Treat your pet after examination?
Call you with the findings of the examination and an estimate of treatment cost prior to treating your pet?
Consent for Treatment:
The actual cost and nature of medical services will be determined by the attending Veterinarian. If the actual anticipated cost exceeds 10% of the maximum estimated cost, Berryhill Animal Hospital will require your authorization before further treatment. In the event that a life-threatening condition should develop and we are unable to contact you, we will proceed with any and all life-saving measures available. By submitting this form, you are authorizing Berryhill Animal Hospital to proceed and accept full financial responsibility for all diagnostic tests and treatment included in the above estimate for services and for any additional emergency services should they be necessary. Additionally, by your digital signature, you are verifying that you are at least 18 years of age. Payment is expected at the time of discharge unless prior arrangements have been made and approved by our hospital office manager.

Telephone Number where you can be reached today:^*

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