Express Drop-off Form | Family Vet
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280 Piney Forest Rd, Danville, VA 24540
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(434) 836-2499
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Keep pets looking and feeling their best with our grooming services.
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Express Drop-Off Form
First Name*
Last Name*
Street Address*
Address Line 2
State / Province / Region*
City*
ZIP / Postal Code*
Country*
Home Phone*
Work Phone*
Co-Owner’s First Name*
Co-Owner’s Last Name*
Co-Owner Phone number*
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*
Select time
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
Preferred Pick up Date*
Preferred Pick up Time
Select time
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
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 color?
Which number should Mallory, our groomer call to clarify scheduling and treatment?
I need refills of:
Frontline Plus (Flea and tick control)
Revolution (flea and heartworm prevention)
Bravecto (3month chewable flea and tick preventative)
Other
Food
I need refills of:
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 $________
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