Drop Off Form

Blaicher Veterinary Health Care

330 Main St.
Bedminster, NJ 07921

(908)234-0650

www.blaicherveterinaryhealthcare.com

Drop Off Form

Date (required) :
Client's Name (required)
First Name (required)
Last Name (required)
Pet's Name (required)

Pet's Breed (required)

Sex: (required)

Male
Male Neutered
Female
Female Spayed


Please list any problem(s) that your pet is having, including timeline and duration, any previous major medical problems and anything else we should know: (required)

Primary Complaints (check all that apply): (required)
Anorexia
Limping
Trouble Walking
Lethargy
Debris in Ears
Runny Nose
Runny Eyes
Painful
Coughing
Sneezing
Growth/Lump
Hair Loss
Itching
Blood in Urine
Difficulty Urinating
Blood in Stool
Diarrhea
Vomiting
Other
Has your pet had any changes with the following? (please check those that apply):
Weight: (required)

No Change
Increase
Decrease


Defecation: (required)

No Change
Increase
Decrease


Urination: (required)

No Change
Increase
Decrease


Appetite: (required)

No Change
Increase
Decrease


Drinking: (required)

No Change
Increase
Decrease


Has your pet been fed today? If yes please provide details / time of feeding: (required)

What is your pet's diet? (required)

Has your pet been seen by another veterinarian for treatment? If so, please list the name of the clinic: (required)

May we call them for records? (required)

Yes
No


What medications (if any) has your pet received in the last 24 hours? Please list name of medication, dose, and time given (NA if this section does not apply): (required)

What vaccinations, if needed, would you like us to give your pet today? (Dog) (required)
Fecal
Heartworm Test
Bordatella
Distemper
Rabies
NA
What vaccinations, if needed, would you like us to give your pet today? (Cat) (required)
FeLV/FIV Test
Feline Leukemia
Rabies Only
Rabies/FVRCP Combo
NA
Are you interested in heartworm and flea/tick prevention? (required)

Yes
No


Please read and select ONE of the following: (required)

I authorize treatment up to a certain amount (see below)
Please call me with an estimate before performing any diagnostics/treatments, except in the case of an emergency
I authorize testing and treatment and place no limit on financial constraints


If you authorize treatment up to a certain amount, please indicate the amount here:

Do you authorize injectable sedation if your pet cannot be handled for any reason? (required)

Yes
No



Payment is due for the services rendered at the time of pickup. In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize Blaicher Veterinary Health, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.
Do you agree to the above statement? (required)

Yes
No



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