* Please note: Filling out this form does NOT mean you are scheduling an appointment. Client name:* First Last Spouse or other responsible party:* Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Cell:Email* Pet owner’s date of birth* MM slash DD slash YYYY Pets Name* Animal* Age* Sex* Breed* Phone #(s) where you can be reached today* Briefly describe the problem*Duration of problem:* (hours, days, weeks, months, lifetime)Check ALL Symptoms:* Vomiting Weight Gain Weight Loss Urinary Leaking Urinary Straining Poor Appetite Coughing Diarrhea Hair Loss Excessive scratching Excessive foot licking Odor in Mouth Odor on Body Excessive water intake Ear Problem Scooting Limping Eye Problem Fleas Lump/Bump Listless Sneezing List ANY medications or supplements your pet is taking:Would you like your pet to receive a nail trim while he/she stays with us (additional fees apply)?* Yes No Would you like your pet to receive a bath while he/she stays with us if well enough?* Yes No Minimum Charge for drop-off is $87.50 (Examination/Observation) CHECK ONE:* I authorize Turquoise Animal Hospital and its employees to proceed with diagnostics and treatment on my pet PRIOR to contacting me not to exceed $___________. I understand I am responsible for all charges at the time of pick up. Please examine my pet but DO NOT proceed with any diagnostics or treatment before contacting me at the above number(s). This will delay treatment if we cannot contact you! $ Ammount:* As a drop off I understand that my pet will be examined on a “time available” basis. Examination MAY be delayed several hours depending on the appointment or surgical scheduling. If anesthesia is required I understand the risks associated with anesthesia.* I UNDERSTAND AND AGREE TO THE ABOVE.Owner’s Signature*Date* MM slash DD slash YYYY
