Patient Drop Off Form in Knoxville, TN | Rocky Hill Animal Hospital

Patient Drop Off Form

Owner's Name
First Last
Pet's Name
First
Best Contact Phone # Today
Reason for Examination #1
Reason for Examination #2
If necessary for examination, do we have permission to sedate your pet?*
- Yes
- No
When did you first notice the problem?
Have you treated your pet with anything at home?
Are there any other problems your pet might have of which we should be aware?
To effectively diagnose and treat many conditions, diagnostics such as x-rays, blood work, and other procedures may need to be performed. We will notify you by phone, ask for your permission to treat, and provide an estimate before undertaking these tasks.
***In the event of a life-threatening emergency, we will make every attempt to stabilize your pet and notify you as to the extent of the problem as soon as possible.
***I also authorize RHAH to dispense Capstar—a safe, proven flea control medication for an additional $4.50 (under 25lbs) or $5.00 (over 25lbs) if any evidence of a flea infestation is noted on my animal.
I HEREBY AUTHORIZE ROCKY HILL ANIMAL HOSPITAL, ITS DOCTORS AND STAFF, TO GIVE STANDARD AND ACCEPTED TREATMENT NECESSARY FOR THE WELL BEING OF MY PET, AND AGREE TO BE RESPONSIBLE FOR ANY AND ALL COSTS INCURRED IN CONNECTION WITH TREATMENT. I ALSO AUTHORIZE EMERGENCY TREATMENT IN THE EVENT THAT I CANNOT BE REACHED BY TELEPHONE IN A TIMELY MANNER. I UNDERSTAND ONLY THE MINIMUM DIAGNOSTICS AND/OR TREATMENT W ILL BE ADMINISTERED TO MY PET UNTIL I CAN BE CONTACTED FOR DIRECT AUTHORIZATION.
Full name as signature
Date
MM slash DD slash YYYY