Drop-off Form for Cornwallis Road Animal Hospital

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

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.

Accept
Decline

Give medication in the hospital and prescribe for home use if needed for my pet.

Accept
Decline

Use fluid therapy for my pet if needed as determined by the doctor.

Accept
Decline

Update annual vaccinations or recommended diagnostic test; e.g. heartworm, medication rechecks, Feline Leukemia testing.

Accept
Decline

What 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.

Accept

In 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.

Accept

I 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.

Accept

While 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.

Accept

Electronic Signature*

Owner/Responsible Party

Date*

DROP-OFF FORM

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