Drop Off Consent Form Lots of love will be given to your pet during their stay with us! This form authorizes your pet’s hospitalization and delivery of your approved care for your pet. Please fill this form out completely and accurately.* Indicates required informationPet’s Name(Required) Primary Contact Name(Required) First Last Phone Number (please be prepared to answer calls while your pet's hanging out with us)(Required)COVID-19 Risk Assessment (recent* means within 14 days)(Required)Please read carefully and select the most accurate choice.I've had known contact with a person that has tested positive for coronavirus.I've had recent* fever or respiratory disease symptoms.None of the above. I've been a social distance warrior and I've got my face mask ready for this appointment.If you've had recent exposure or clinical signs associated with COVID-19, please be responsible and send someone else to drop-off and pick-up your pet or reschedule for a later date. This is extremely important for the safety of our staff and other clients. We greatly appreciate your honesty and empathy. We agree with your pet, you're the best.Chief Complaint / Reason for Visit(Required)How's the appetite recently?(Required)Normal/UnchangedIncreasedDecreasedAny recent change in thirst?(Required)Normal/UnchangedIncreasedDecreasedAny change in ability or desire to exercise?(Required)Normal/UnchangedIncreasedDecreasedAny of the items below a current problem?(Required)ItchinessVomitingDiarrheaCoughingSneezingLimping/StiffnessIf you selected yes on anything above, please describe for how long and how bad. Any chance your pet got into anything weird (trash, stash, or other mishmash)?Here's an opportunity to tell us something we didn't ask, but you think might help shed some light on you pet's current situation.What are you currently feeding? Have you changed in the last month?(Required) Please list any and all prescription medications your pet is currently receiving (including dosage and when last given). Please click the green plus sign to add another medication. We know this can be a pain, but honestly it can be really important for us to know. If your pet is currently not receiving any prescription meds, please type "none".(Required)MedicationHourMinuteAM/PM Add RemoveDoes your pet get any non-prescription medications or supplements? If so, please list below.Which heartworm and flea preventives are you giving? When (approximately) was the most recent dose?(Required) Any history of drug allergies of anesthetic complications? If so, please explain.Are there any refills of preventives, medications, or supplements that you would like us to take care of today? Please list below.Anything your pet absolutely hates (i.e. anything we should know to avoid scaring you pet into biting us)? Examples would include nail trims, belly rubs, those creepy dolls dressed as clowns, or touching the tail.In an effort to keep things efficient for both of us, please tell us your comfort level regarding treatment plan authorization. Please note, regardless of your choice, we will happily review the plan with you prior to pick-up:(Required)Select oneI'm comfortable with PAZ starting treatment prior to direct authorization for services less than $250Please clear all charges with me prior to starting treatmentI authorize testing and treatment at the doctor's discretion regardless of costIn case of life-threatening emergency, and if I cannot be immediately contacted, I authorize my veterinarian and the staff at PAZ Veterinary to:(Required)Select oneProvide any interventions deemed necessary, including, but not limited to, CPRNo CPR, but ensure patient comfort. Euthanize if sufferingDo not resuscitate (DNR)Your pet will be monitored and cared for by and under the direct supervision of a veterinarian. Your pet will also be thoroughly and regularly monitored. We will contact you with updates or in the event of an emergency. Feel free to call at any point for an update on your pet and we will happily answer any questions you may have.I hereby consent to and authorize treatment for my pet as deemed medically appropriate in the veterinarian’s professional judgement. I accept financial responsibility for any charges incurred during my pet’s care at your facility, including any emergency care and associated charges. I understand payment is due at the time of my pet’s discharge from the hospital and will render payment in full. Financing is available through ScratchPay during times of financial constraint.Date(Required) Signature(Required)Please only click "Submit" once and do not leave this page! This may take a few seconds. From everyone at PAZ - Thank You!NameThis field is for validation purposes and should be left unchanged.
