Owner's Last Name (required)
Pet's Name (required)
Please leave this field empty.
Primary Phone Number (required)
Secondary Phone Number
Your Email (required)
What is the main concern with your pet? (required)
How long has this problem been going on? (required)
Has your pet been treated for this problem before? (required) ---YesNo
If Yes, where?
For any problems or concerns, please use the "Additional Information" field (near the end of this form) to describe how long it has been occurring.
Drinking: ---Less than NormalNORMALMore than Normal
Eating: ---Less than NormalNORMALMore than Normal
My pet eats:
Urinating: ---Less than NormalNORMALMore than Normal
My pet: Is strainingHas discolored urine
Defecating: ---Less than NormalNORMALMore than Normal
The stool is: ---SoftNORMALHard
The stool is: ---NORMALAbnormal
If abnormal, please check any that apply: BloodMucousBlack/Tar-like
Current Medication: Flea PreventionHeartworm Prevention
Over-the-counter or human medication given:
Current Medical Conditions (check any that apply): Epilepsy (Seizures)DiabetesHyperthyroidHypothyroidHeart DiseaseAllergiesKidney DiseaseArthritis
Any allergies or adverse reactions (medications, vaccines)? ---YesNo
If Yes, explain:
We are pleased to offer the drop off service as a convenience to our clients. Our doctors will examine your pet as soon as possible. We prioritize critical patients based on the severity of illness. For non-urgent conditions, unless you have scheduled a drop-off appointment with a specific doctor, we cannot guarantee when your pet will be ready for discharge.
If indicated at the time of Exam, I give the doctor permission to:
Sedation and/or anesthesia of my petPerform radiographs (x-rays)Perform bloodwork (CBC, Chemistry, Heartworm Test, etc.)Perform Other Lab Tests (Fecal, Urine, etc.)Dispense MedicationVaccinate Based on CLAH Records
I authorize diagnostics and treatment up to: I DO NOT Authorize diagnostics or treatment if I cannot be contacted$300$400$500No LimitOther (describe below)
I am aware that if the doctor cannot reach me at the time they evaluate my pet, and I have elected not to proceed without being contacted I may be asked to schedule an appointment for further diagnostics and treatment at a later time for an additional exam fee.
I, the undersigned, am the owner or authorized agent of the owner of the pet named above, and have the authority to consent to medical procedures. I authorize Cheat Lake Animal Hospital to obtain all medical records regarding my pet from any/all other hospitals where my pet has been treated or examined and to release all medical records regarding my pet to any other hospital. I understand that Cheat Lake Animal Hospital will exercise every reasonable precaution to ensure the safety of my pet while in their care but there is a risk of complication(s) with any medical procedure, treatment, vaccination, surgery or anesthesia (if checked above) including the possibility of death. The nature and risks of such complications have been explained to me and any questions have been answered so I authorize and direct the veterinarians or associates of Cheat Lake Animal Hospital to perform the above procedures, diagnostics, and treatments for my pet with my consent. I understand that there is no guarantee, nor can one be made as to the results of any therapy. I understand that if my pet has an infectious disease that requires my pet to be housed in the isolation ward, or if my pet stays overnight, I will be charged a hospitalization fee. I agree to pay, in full, for services rendered. I understand that payment is due and expected on the day service is rendered.
Fees are due at the time of pick up and can be paid by cash, check, credit card or Care Credit. If Care Credit is being used, please tell the receptionist at drop off.
I am an authorizing owner/agent. (required)
Please type your name here in place of a signature (required):