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Patient Drop Off Information

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Patient Drop Off Information Form

Patient Drop Off Information

Client's Name *

First

Last

Telephone Number to reach you today:

Pet's Name

Breed

Gender

Has your pet been seen by us before?

Pet Information

When was your pet's last meal?

What did they eat?

What medications (If any) has your pet received in the last 24 hours?

Is your pet sensitive or allergic to any medications or food?

Please List

Pet Symptoms and Duration

My pet is lethargic

How Long?

Water intake has

increased
decreased
not changed

Appetite has

increased
decreased
not changed

My pet has been vomiting

It started:

Last vomited

How many times a day

My pet has

normal stool
seems constipated
has diarrhea

It started

Last episode

How many times a day

Has your pet had access to foods other than their normal diet?

What could your pet have gotten into?

My pet has

lost weight
gained weight
no weight change

I accept financial responsibility for charges incurred for this pet

Signature

Date

My pet is

lame
sore
has been injured

Specify where the injury is located

What is bothering your pet?

When did it start?

The problem has

worsened
improved

The problem has

never happened before
has been occurring for a long time

Please describe the problem(s) your pet is having, pertinent history leading up to the current condition, any previous major medical problems, and what you would like us to do below:

Diagnostics/Test

Would you like us to perform a diagnostic test?

What diagnostic test would you okay and the doctor will only perform the ones them think are necessary (Taxes not included)

Blood work ($207)
Fecal ($28)
Feline FeLV/FIV ($51)
Parvo Test ($51)
Heartworm/E. Canis/lyme/anaplamosis 4dx ($48)
Ear cytology ($25)
Skin cytology ($20)
Nail trim ($19)
Feline vaccines ($94)
Canine vaccines ($104.40)
Canine vaccine w/ Fecal 4dx ($162)

Contact preference for findings of the examination with estimate of diagnostics before performing any diagnostic test

Call
Text

Is there anyone in the household that has a peanut allergy that would require us to not potentially use peanut butter during an exam to make a pet-focused?

A doctor or technician will call with potential treatment and findings after diagnostic test have been performed.

I accept financial responsibility for charges incurred for this pet.

Signature

Date

Comment

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If you are searching for a trusted veterinarian in Corbin, Woodbine, North Corbin, or the surrounding areas, look no further than Corbin Animal Clinic. We are always accepting new patients and would be honored to be entrusted with your companion’s care.

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Address

1220 Cumberland Falls Hwy,
Corbin, KY 40701

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Contact

Email: [email protected]
Phone: 606-523-1099

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Hours

Mon-Fri: 8:00 am – 5:00 pm
3rd Wednesday of Each Month: Closed from 12 pm – 1:30 pm for Staff Meetings
Sat: 8:00 am – 1:00 pm
Sun: Closed

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First

Last

Email *

Phone

How can we help you? *

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