Zebulon Animal Hospital
Zebulon NC Veterinarians & Pet Care
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Drop Off Form
Drop Off Form
Thank you for trusting us with your pet’s care. The following information will be used to help our veterinary team accurately complete your pet’s medical history for today's visit.
Client Name
(Required)
First
Last
Pet Name
(Required)
Date
MM slash DD slash YYYY
We will need to be able to contact you or someone with permission to make medical and financial decisions.
Me; Phone Number:
OR
Someone Else; Their Name:
First
Last
Their Phone Number:
Reasons for Visit (check all that apply)
Healthy Visit/Vaccinations
Sick Visit
Recheck
Weight Management Question
Injury
Illness
Other
Please describe the injury.
Please describe the illness.
Please describe other reason(s).
Concerns about your pet? (check all that apply)
NO CONCERNS
Eating Issues
Drinking Issues
Bad Breath
Shaking Head
Weight Loss
Weight Gain
Eye Issues
Ear Issues
Excessive Sleeping
Itching/Scratching
Excessive Grooming/Licking
Difficulty Rising
Limping/Lameness
Vomiting
Car Sickness
Diarrhea
Scooting
Skin Masses/Lesions
Urination Issues
Behavioral Issues
Other
Please describe other concern(s).
What do you feed your pet?
When did your pet last eat (indicate am/pm and day)?
Has your pet ever had any adverse reactions to medications?
Yes
No
If yes, please describe.
Has your pet ever had any adverse reactions to vaccines, including pain?
Yes
No
If yes, please describe.
Is your pet currently taking any medications?
Yes
No
If yes, please list them.
What brand of heartworm prevention is your pet on and when did you give the last dose?
Are any medication refills needed?
Yes
No
If yes, please list them.
If your pet is here for a sick or recheck visit, please answer the following.
How long has your pet been sick?
Have the symptoms/issues gotten better or worse since you first noticed them?
Have you tried any treatments at home?
Yes
No
If yes, what have you tried? (include any medications, topical treatment, diet and exercise)
Has your pet had these symptoms/issues before?
Yes
No
If yes, when/how often?
Has there been any exposure to toxins/garbage/abnormal food or treats/medications?
Yes
No
If yes, please describe.
If your pet is receiving anesthesia today, please confirm below.
Preanesthetic Blood Panel
This is performed for every patient and is included in the estimate for every general anesthetic procedure. Some abnormal results may warrant additional testing and your medical team will contact you to discuss additional evaluation. In some instances, the anesthetic procedure may be postponed or cancelled.
I understand.
Pain Management
Pre-and postoperative pain medications are given as needed to every anesthetic patient. If determined to be medically indicated, pain medication to go home for your pet may also be recommended and additional charges will apply.
I understand.
Additional questions for all visits
Is there anything else you would like to discuss with the doctor today?
Have you or your pet had any exposure to any person positive for COVID 19 or are you or your pet showing any signs or symptoms of COVID 19?
Yes
No
If yes, please describe.
Please check any additional services you would like your pet to receive.
Note: additional charges will apply.
Heartworm Prevention
Flea & Tick Prevention
Microchip
Nail Trim
Express Anal Glands
Other
If other, please describe.
I, the undersigned owner, or owner's agent, of the pet mentioned above hereby authorize the doctors at Zebulon Animal Hospital to perform the above anesthetic and surgical procedure(s) for my pet. I understand that some risk always exists with anesthesia and/or surgery, and that I am encouraged to discuss any concerns about those risks with the attending veterinarian before the procedure(s) is/are initiated. I understand that Zebulon Animal Hospital is not staffed overnight and I accept any risks incurred by leaving my animal overnight unattended. I understand that I have the option to transport my animal to an overnight/24-hour facility if I so desire.
Owner/Responsible Party Electronic Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
We are now offering Remote Vet Care!
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Zebulon NC Veterinarians & Pet Care
Zebulon NC Veterinarians & Pet Care
