Sick Pet Drop Off Form « Manchaca Village Veterinary Care

Full name of owner:

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Name of pet:

Symptoms:

For item(s) checked above:

How long have symptoms been noticed?

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How often have symptoms been occurring?

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Are symptoms improving, staying the same, or worsening?

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Is your pet currently on heartworm preventative?

Yes No

If needed after the doctor’s exam, may we SEDATE, do preliminary bloodwork, urinalysis,
and/or X rays?

Choose one.

Yes, please proceed with whatever testing and treatment is needed.

Yes, please proceed with testing and treatment up to dollars without contacting me.

No, I must be contacted before any testing or treatment is performed (other than what I may have already authorized). Your pet will NOT receive any (or additional) treatment until we are able to reach you.