Express Drop-off Form

First Name*

Last Name*

Street Address*

Address Line 2

State / Province / Region*

City*

ZIP / Postal Code*

Home Phone

Work Phone

Co-Owner First Name*

Co-owner Last Name*

Co-Owner Phone

Email*

How do you prefer to be contacted?

Email Text Phone Other

If Other, please specify:

Pet's Name*

Age

Breed

List other pets name/age/breed here

Date of last heart worm preventative

Name of product

Date of last flea & tick preventative

Name of product

Date of last vaccines

Name and Phone # of Vet Office

Date of last laboratory testing

Name of Vet

How much time each day does your pet spend outside?

What types of dental care to you do for your pet?

Please list all food and treats your pet eats:

Are you enrolled in our health savings plan?

Yes No

Do you have an insurance form for us to fill out?

Yes No

Drop off Date

Drop off Time

Preferred Pick up Date

Preferred Pick up Time

If your pet has been previously groomed, would you like the same hair cut?

Yes No

Would you like:

Hair bow? Bandana? Nail color? Hair bow?

Which number should Mallory, our groomer call to clarify scheduling and treatment?

I need refills of:

Sentinel (Heartworm prevention) Frontline Plus (Flea and tick control) Revolution (flea and heartworm prevention) Bravecto (3month chewable flea and tick preventative) Other

Food

Check box below that best applies

I would like my pet to have all the health care that the doctor deems necessary which may include vaccines, laboratory testing, xrays, and other procedures and tests. I would like the doctor to call me before performing any tests or procedures (I understand that certain vaccines and tests are required for the safety of all pets staying in the hospital) I would like the doctor to call me if the bill is expected to go over $________

Express Drop-Off Form