Exam Drop off

please complete the form below

    CLIENT INFORMATION

    PET INFORMATION

    Name

    Species
    CanineFelineOther

    Breed

    Age

    What is the reason for your visit?

    Is your pet

    Having any vomiting?
    If yes, please describe.
    NoYes

    Having any diarrhea?
    If yes, please describe.
    NoYes

    Having any coughing?
    If yes, please describe.
    NoYes

    Having any sneezing?
    If yes, please describe.
    NoYes

    Have you noted that your pet is experiencing weight loss?
    If yes, please describe.
    NoYes

    Is your pet experiencing any pain?
    If yes, please describe.
    NoYes

    Pet's appetite?

    Pet's drinking?

    Pet's urination?

    MEDICATION/SUPPLEMENTS

    Is your pet on any medications?
    If yes, please list name, dose, and how often administered.
    NoYes

    Does your pet receive any supplements?
    If yes, please list drug name, dose, and how often it is administered
    NoYes

    Does your pet have any known medication allergies?
    If yes, please list drug name
    NoYes

    Does your pet have any exposure to toxins including:
    Raisins, grapes, lilly flowers, chocolate, onion, garlic, antifreeze, xylitol (sugar free products), mushrooms, acetaminophen.
    NoYes

    Does your pet have any previous medical conditions?

    CONSENT & AUTHORIZATION FOR LIFE SAVING TREATMENTS

    In the unfortunate event that your pet experienced a cardiopulmonary arrest (his/her heart stops or he/she stops breathing on their own), we at FRVH need to know you and your family’s wishes on how you would like us to respond. Some families choose for us to pursue CPR (cardiopulmonary resuscitation) in an attempt to re-establish your pet’s heartbeat. Due to many understandable circumstances, some families ask that CPR is not pursued, designating their pet at DNR (do not resuscitate). Please know that we support and respect your family’s decision regardless of your reasoning. Please make your selection below:

    I wish to select CPR, including chest compressions and manual ventilation. I acknowledge the risks associated with CPR and consent to the initial resuscitation charges of $500-1000, knowing this total may substantially increase if extensive intervention is needed to recover my pet.I wish to select DNR, acknowledging that no life-saving measures will be deployed should my pet’s heartbeat or breathing capabilities stop.

    CONSENT

    I am over 18 years of age and am the authorized owner and/or guardian for the aforementioned patient. I authorize Folsom Ranch Veterinary Hospital and Urgent Care (FRVH) to perform treatment/procedure(s) on my pet(s) as recommended by FRVH's Veterinarians and employees. I was informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved. I confirm that by signing below, I understand the inheritable and sometimes unforeseen risks associated with veterinary care and release all liability, without exceptions, from Folsom Ranch Veterinary Hospital (FRVH) while treating my pet(s). I understand that payment is required for all services at the time they are rendered unless prior arrangements have been made with hospital management. I understand that deposits may be required prior to certain procedures. In the event that a refund is due and the original payment is a credit card, the refund will be posted against the original credit card. I also authorize FRVH to use pictures of my pet(s) for learning or marketing purposes. Consent will apply to all future pets added to this account unless and until I provide a written revocation of that consent.

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