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Well Patient Drop-Off Form

Client Name(Required)

Pet’s Name(Required)

Contact number today(Required)

What are the main concerns you would like the doctor to address today?(Required)

Current Medications, dosages and frequency?(Required)

Current Diet, amount and how often being fed?

Has there been any recent coughing / sneezing / vomiting / or diarrhea?

Is your pet having normal urination and defecation?

Would you like any additional services today? Please let us know at check-in (Nail trims are included with annual exams if pet allows)

Ear cleaning- $47.50

Anal Glands- $43.50

Annual Preventive Lab work for pets <7yrs $124

Annual Preventive Lab work for pets >7yrs $220

Authorize(Required)

I authorize Georgetown to perform the agreed services and understand that actual costs may vary based on the doctors exam today

Please call me first prior to any additional diagnostics being performed.

In the event of a medical emergency would you like us to perform life saving measures(Required)

Yes

No

Signature(Required)

Date(Required)