Patient Drop Off Form

Owner's Name*

First Last

Phone*

Pet name*

Contact Name*

Contact Phone*

Who should we contact if further information is needed or treatment is necessary?

Reason for visit*

Have you noticed any of the following?:

Other

Please explain

Treatments requested (Canine)*

Canine Treatments - Other

Treatments requested (Feline)*

Rabies
FVRCP
FeLV
Fecal
FeLV/FIV/Heartworm test
Urinalysis
Urinalysis
Micro-chip
Other

Treatments requested (Other)*

Confirm Xrays*

Yes
No

Name*

Enter Name

Date:*

Confirm Ultrasounds*

Yes
No

Name:*

Please enter your Name

Date*

Confirm IV Fluids*

Yes
No

Name:*

Please enter your Name

Date:*

Sedation:

To treat wounds, abscesses, or to take quality radiographs, ultrasound, sedation or anesthesia is often required. Anesthetic episodes carry an inherent risk. The nature of the anesthesia procedure and risks have been explained to me and I realize the results cannot be guaranteed. I am also aware that unforeseen events (including death) resulting from the procedure(s) will not relieve me of my obligation to all reasonable costs incurred regarding the animal.

If required, do we have your permission to sedate/anesthetize pet?*

Yes
No

Name:*

Please enter your Name

Date*

Administration

In the event I cannot be reached for further contact or authorization, I give the doctors and assistants at Blue Ridge Veterinary Associates permission to treat this animal in any manner they deem appropriate for the benefit of its health and welfare. I understand that BRVA will leave a message when possible, if unable to contact me directly. I certify that I am the owner or responsible agent for the animal described above. I understand that I am responsible to ask for a quote if finances are a concern. Additionally, I am responsible to inquire about current charges or daily balances for the hospitalized patients. If you have any questions or further concerns, please contact our staff, we are open 24/7.

Drop off fee*

I understand that there is a drop off fee

Name:*

Please enter your Name

Date*