Countryside Companion Veterinary Services

7659 Old State Road,
Holly Hill, SC 29059

(803)496-5037

www.huttoveterinaryclinic.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
Female
Male Neutered
Female Spayed


Please describe the problem(s) your pet is having, including the timeline, any previous major me problems, and what you would like us to do: (required)

Primary Complaints (check all that apply): (required)
Vomiting
Diarrhea
Blood in Stool
Difficulty Urinating
Blood in Urine
Itching
Hair Loss
Groth/Lump
Sneezing
Coughing
Painful
Runny Eyes
Runny Nose
Debris in Ears
Lethargy
Trouble Walking
Limping
Anorexia
Other

Has your pet had an increase or decrease in any of the following (please check those that apply):
Drinking (required)

Increase
Decrease
No Change


Appetite: (required)

Increase
Decrease
No Change


Urination: (required)

Increase
Decrease
No Change


Defecation: (required)

Increase
Decrease
No Change


Weight (required)

Increase
Decrease
No Change


Was your pet fed today? If Yes, please list the time of meal. If No, please type NA (not applicable): (required)

What is your pet's diet? (required)

Has your pet been seen by another veterinarian for treatment? (required)

Yes
No


May we call for records? (required)

Yes
No


If yes, name of clinic? (required)

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

Yes
No


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

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


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) :

Payment is due for the services rendered at the time of pickup. In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize Hutto Veterinary Clinic, 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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