Drop-Off Form Due to the current COVID recommendations, we have elected to use this form to streamline the drop off process. Please complete this form and let us know when you are ready for a staff member to come out to get your pet by calling (919) 489-9194. Thank you for your patience.Client Name*Patient Name*Date Date Format: MM slash DD slash YYYY Being responsible for the above-described animal, I have the authority to grant you my consent to receive, prescribe for, treat and/or operate on my pet. I authorize the personnel of Cornwallis Road Animal Hospital to: Text Call Best Contact Number*Perform bloodwork as recommended for my pet.AcceptDeclineGive medication in the hospital and prescribe for home use if needed for my pet.AcceptDeclineUse fluid therapy for my pet if needed as determined by the doctor.AcceptDeclineUpdate annual vaccinations or recommended diagnostic test; e.g. heartworm, medication rechecks, Feline Leukemia testing.AcceptDeclineWhat do you feed your pet and when was he/she last fed?List of current medications your pet is taking, and when the last dose(s) were given.Please list the reasons why we are seeing your pet today, and any concerns you may have.I understand a written estimate for these services will be made available upon my request.AcceptIn an effort to maintain a flea-free hospital, if fleas are found on my pet upon admittance to Cornwallis Road Animal Hospital, I agree to treatment with an appropriate oral or topical flea treatment to prevent spread of those parasite to other hospitalized patients. I understand I will be charged for this treatment.AcceptI understand that Cornwallis Road Animal Hospital is not responsible for personal belongings that are left with your pet. We do provide towels and blankets in the cages where all patients are kept.AcceptWhile I accept that all procedures will be performed to the best of the abilities of the hospital's staff, I understand that no guarantee has been made regarding the results that may be achieved. I agree to assume financial responsibility and provide payment at the time that services are rendered.AcceptElectronic Signature*Owner/Responsible PartyDate* Date Format: MM slash DD slash YYYY
