Drop-Off Appointments:

If you are a new client please call 336.275.7266 for an appointment.

For your convenience, we have provided an online form if you intend to drop your pet off for treatment. Please fill out all of your information and send to us prior to your appointment.

Owner Information:

* indicates required field

* Name:

* Address:

* City:

* State:

ZIP Code:

* Home Telephone:

Work Telephone:

* Cell (Other):

Pet Information:

* Pet's Name:

* Species (dog, cat, etc.):

Diet:

Heartworm Prevention:

If other, please specify:

Date last given:

Flea prevention:

If other, please specify:

Date last applied:

Reason for Visit:

Vaccines:
(Skip rest of section if vaccinating only)

Yes No

Describe medical problem:

How long has your pet had this condition?

Has your pet been treated for this problem?

Yes No

If yes, what were the treatments?

Did the treatments help?

Yes No

Current medications (if any):

	Name of Medication	Amount Given	Time Given
Medication 1
Medication 2
Medication 3
Medication 4

Does your pet appear to be in pain, if so where?

Please click on all symptoms that your pet is showing:

Demeanor:

Normal Depressed/Lethargic

Vomiting:

Yes No

Appetite:

Normal Increased Decreased

Diarrhea:

Yes No

Water intake:

Normal Increased Decreased

Coughing:

Yes No

Urination:

Normal Increased Decreased

Sneezing:

Yes No

Limping:

Yes No

If limping, where?

Is your pet sensitive to any medication or food?
(if yes, please list)

Other symptoms:
(Please list)

Would you like us to:

Treat your pet after examination

Call you with the findings of the examination with an estimate of treatment cost prior to our treating your pet*

*please note that we will need to be able to contact you regarding your pets examination prior to any treatment.

Disclaimer: (To be filled out upon your visit)

Professional fees are to be paid in full at the time services are performed.

In admitting my pet (____________________) for diagnostics, treatment or surgery, I authorize the veterinarians of Southwoods Animal Hospital and their support staff to administer such treatment and/or perform such diagnostic or surgical procedure as deemed necessary.

Vaccinations:
All pets boarding in our hospital are required to be currently vaccinated against RABIES and DISTEMPER, and have a current negative intestinal worm exam. Additionally, all dogs must be currently vaccinated against PARVO and BORDETELLA. If your pet is not a client of Southwoods Animal Hospital, please bring proof of vaccination or your pet's current veterinarian's contact information with you.

Parasite policy:
Your pet will be inspected for parasites upon admission by our kennel staff. Any pets showing obvious signs of parasites (i.e. fleas) will be treated at owner’s expense.

I agree that I, or an authorized agent of mine, will pick up my pet and pay for all accrued charges within 5 days of receiving written or oral notification that my pet is ready to be released from the hospital. Such notice will be given at the address maintained on the hospital's patient/client record. I agree that if I fail to comply with this policy, Southwoods Animal Hospital may handle this abndonment in the best interests of the animal and the hospital.

Signature:
(To be filled out upon your visit)

Today's Date:
(To be filled out upon your visit)