West Alabama Animal Clinic

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DROP-OFF RELEASE FORM
Today's Date: 
Owner's Name:
Owner's Phone Number:
Owner's Address:
Street 1:

Street 2:

City:
State:
Zip:
Pet's Name:
Reason For Visit:
Will Your Pet Be Fed Prior To Arrival?
Yes
No
Is Your Pet On Heartworm Prevention?
Yes
No
If You Answered "Yes" To The Previous Question And You Would Like To Refill Your Pet's Heartworm Medication, Then Please Specify The Name Of The Desired Medication:
Is Your Pet On Flea Prevention?
Yes
No
If You Answered "Yes" To The Previous Question And You Would Like To Refill Your Pet's Flea Prevention Medication, Then Please Specify The Name Of The Desired Medication:
Has Your Pet Been Checked For Intestinal Parasites In The Last 6 Months?
Yes
No
Has Your Pet Ever Had Any Reaction To Medications?
Yes
No
Has Your Pet Ever Had Any Reaction To Vaccines?
Yes
No
Has Your Pet Ever Had Any Reaction To Anesthesia?
Yes
No
Is Your Pet Currently On Any Medication(s)?
Yes
No
If "Yes", Please List The Name Of The Medication And The Dosage:
HAS YOUR PET SHOWN ANY SIGN OF THE FOLLOWING?:
Vomiting?
Yes
No
Diarrhea?
Yes
No
Listless?
Yes
No
No Appetite?
Yes
No
Weakness?
Yes
No
Coughing?
Yes
No
Gagging?
Yes
No
Scratching?
Yes
No
Shaking Head?
Yes
No
Scooting?
Yes
No
Seizures?
Yes
No
Abnormal Amount Of Urination?
Yes
No
Abnorma Amount Of Drinking?
Yes
No
Limping?
Yes
No
Abnormal Weight Loss Or Gain?
Yes
No
Unusual Lumps Or Bumps?
Yes
No
TESTS & SERVICES TO BE PERFORMED DURING THIS VISIT:
Puppy/Kitten Wellness Exam
Annual Wellness Exam
Intestinal Parasite Exam
Deworm (If Needed)
Heartworm Test
FELV Test
FIV Test
Bath
Dip
Grooming
Other (Please Specify):
May We Sedate/Anesthesize Your Pet If Necessary?
Yes
No
By Clicking The "Submit" Button, I Agree With All Of The Following:The practice is to use all reasonable precaution against injury, escape, or death of my pet. The practice and staff WILL NOT be held liable for any problems that develop provided reasonable care and precautions are followed. I understand that ANY problem that develops with my pet while I'm absent will be treated as deemed best by the staff veterinarians and I ASSUME FULL RESPONSIBILITY for the treatment expense involved. I agree to pay fees for all services rendered at the time my pet is discharged from the practice or the service is otherwise terminated. I agree to pay for the reasonable costs of collection, attorneys fees and court costs in the event that collection efforts become necessary. I agree that the venue of this action will be in the county where the practice is located. If I neglect to pick up my pet within 7 days of the date below and do not notify the practice within that time frame, the practice may assume that the pet is abandoned and is hereby authorized to dispose of the pet as deemed best and/or necessary.



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