Drop Off Form in San Jose, CA | Lincoln Avenue Veterinary Clinic

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Client Name*

Cell Phone

Home Phone

Work Phone

Best Number to Reach You*

Cell
Home
Work

Email*

What is the chief problem?*

How long has it been going on?*

Has it gotten:*

Better
Worse
None of the above

Has this problem occurred before?*

Yes
No
None of the above

If yes, when?

Has there been any: (Please check all that apply)*

If yes, describe what comes out, frequency, and how long has it been going on.

Any change in: (Please check all that apply)*

If yes, describe .

Is your pet experiencing any pain?*

Yes
No

If yes, please describe pain.

Is your pet currently on any medications? Please provide name, amount given, frequency given, and strength of each medication.*

There will be an office call charge and hospitalization fee, along with any other fees for other services performed. We will try and contact you BEFORE performing any services beyond the exam, unless it is imperative for the pet's health and safety (in which case we may not wait to contact you and you will still be responsible for those charges and fees).

Please call me before performing any tests or treatments to my pet.
You have my permission to perform laboratory testing ($100 and up), X-rays (1 - $95 / 2 - $180) or other tests needed and to treat my pet as deemed necessary by the veterinarian.

Budget

If other, please specify amount.*

Client's Full Name as Signature*

Date*