Drop-off Appointment Registration Form Drop-off Appointment Registration Name * Name First First Last Last Pet's Name * Pet's Age * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Phone number where you can be reached today * Preferred method of contact for updates * Email Phone Text Presenting Complaints Procedures to be performed Medical History Has your pet recently experienced vomiting, coughing, sneezing, diarrhea? * Yes No If yes, please describe Duration Did your pet eat this morning? * Yes No Is your pet on a special diet? * Yes No If yes, please explain Is your pet current on vaccinations? Yes No Is your pet allergic to any drugs? Yes No If yes, please explain Is your pet taking any medications? Yes No If yes, what medications? Elective Procedures Flush and clean ears - ($23.00) Nail Trim - ($14.95) Express Anal Glands - ($25.00) Heartworm Test - ($36.00) Intestinal Parasite Screen - ($26.55) FIV/FeLV/Feline HWT - ($58.90) Microchip - ($47.00) Do you give us permission to use your pet’s photos and videos for social media & educational purposes? * Yes No Please Read Below: Please reach me at the above number before performing any other necessary procedures, except in the case of a medical emergency. I hereby authorize American Animal Hospital to perform such diagnostic, therapeutic and surgical procedures that are in their opinion, necessary and advisable for treatment and maintenance of my pet's health and well being. The nature of such services has been described to me and to my satisfaction and, while I expect all procedures to be done to the best of the abilities ofthe professional staff, I realize that no guarantee or warranty can ethically, or professionally, be made regarding the results or cure. I also authorize the hospital director and staff to provide veterinary service as required or in emergency circumstances to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further advised in writing, even if! cannot be reached. DNR (Do Not Resuscitate) Request: By checking this box, I am declining a DNR request and understand that I am financially responsible for any costs associated with necessary life-saving measures. I also acknowledge that life-saving measures do not always guarantee a successful outcome, and the effectiveness of such measures can vary based on the nature and severity of the pet's condition. I decline DNR I understand that I assume full financial responsibility for all services rendered. * I understand Signature * signature keyboard Clear Today's Date * Captcha Submit If you are human, leave this field blank.
