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Drop Off Form

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Client First Name*

Client Last Name*

Pet's Name*

Phone*

I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the
animal listed above. You, as the owner, have opted to have your pet admitted to the
hospital for evaluation of an illness or drop off appointment. As this is an optional service
provided by Strong Veterinary Hospital, I understand that the evaluation of my pet will
be worked into the schedule as the veterinarian or hospital personnel see fit and that
there is no guaranteed time when your pet will be evaluated. By admitting your pet to
the hospital, you are agreeing to be financially responsible for at least the cost of an
examination while your pet is here.

Once your pet has been evaluated, the examining veterinarian will contact you at the
number listed above to discuss an estimate for diagnostics and/or treatments. Because
we value your time, please CHOOSE ONE OPTION BELOW regarding how you would
like us to proceed with diagnostics and/or treatments:

Options*

Perform any necessary diagnostics and/or treatments at this time. I agree to assume financial responsibility for these additional charges.

Call me after the examination and provide an estimate of any additional procedures. I understand that if I cannot be contacted at this number, necessary diagnostics and/or treatments will be performed. I agree to assume financial responsibility for these additional charges.

Call me after the examination and provide an estimate of any additional procedures. Do not proceed without authorization. I understand that if I cannot be contacted at this number, no diagnostics and/or treatments will be performed, and I assume all responsibility for any complications this decision may cause for my pet. I also understand that if I decide to have these additional services done later, I have to schedule for a different appointment with separate charges.

Flea control is particularly important for your hospitalized pet and our hospital. Should
we discover that your pet has fleas or evidence of fleas, they will be treated according to
their weight. In this manner, we can ensure the transmission of parasites is prevented
between animals and we maintain a flea-free hospital environment. If we must treat your
pet for fleas, there will be an additional cost added on to the invoice for that treatment.

Signature*

If you decide to leave personal items at the hospital while your pet is undergoing a
procedure (i.e. leash, collar, harness, etc), Strong Veterinary Hospital will not be
responsible for any lost items.

Signature*

I have read and understand this form and accept responsibility for payment of all
charges incurred and services provided to my animal by Strong Veterinary Hospital.

Signature*

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Phone

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Drop Off Form

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734-427-6360

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