Owner Information

Owner Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet Information

Pet's Name *

Breed *

Color *

Reason for visit: *

Vaccine(s)
Recheck
Health Concerns

Please explain: *

How is your pet doing? *

Good, no concerns
Other (Please explain below)

Please explain: *

Medications *

Not on any medications.
Yes, list medications

Please list medications: *

Medicine name & Time last given (AM or PM)

Feeding Information *

Diet Fed
My pet has NO food allergies.
My pet has food allergies.
My pet has not eaten today.

Diet Fed *

How much is fed per day: *

Time last ate anything: *

AM or PM

My pet is allergic to: *

Should any unforeseen procedures be necessary and indicated in the veterinarian’s professional judgment, please select one of the following options: *

I prefer that you proceed with all necessary procedures.
I prefer to be called before any additional procedures. If I cannot be reached, I DO authorize you to proceed with any procedures as deemed necessary by the doctor.
If I cannot be reached by phone, I DO NOT authorize you to proceed with any additional procedures.

I am satisfied after speaking with the staff of Frey Pet Hospital that they will treat your pet as they deem necessary for his/her health, safety, and well-being; however, I do understand that no guarantee of successful treatment can be made. I acknowledge that I have read and fully understand this Authorization for Medical Treatment, the reason why such medical treatment is considered necessary, as well as its advantages and possible complications, if any. I acknowledge that a small area of hair may be shaved in order to obtain a sample.

I understand that payment is due at the time of your pet’s discharge and that a deposit may be required for extensive medical or surgical procedures.

Signature *

Clear Signature

Date *

Please mark the primary phone number that you can be reached at today *

Cell Phone
Home Phone
Work Phone

Cell Phone *

Home Phone *

Business Phone *

Preferred contact method *

Text
Email
Phone

Cell any verify

Please verify your email address: *

Drop-Off Out-Patient Consent Form

Owner Information

Pet Information

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Contact Frey Pet Hospital

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