Drop Off Form If you prefer, you may download a copy here to print and complete. If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Please take the time to complete this form if you are unable to be present for your dog's appointment. First Name * Last Name * Dog's Name * Email Today's Date Phone number where you can be reached today: * Your dog's symptoms (check all that apply): * vomitingdiarrhealethargylamenessincreased thirstincreased urinationincreased appetitedecreased appetiteblood in urineeye dischargesquinting / rubbing eyesshaking headitchy earsitchy skin / rashcoughing / sneezingchewing tail / pawsdifficulty breathingother If you checked "other," please list symptoms here: Please tell us more about your dog's symptoms (e.g. when symptoms started, specific details, which eye/ear/leg is affected, etc.) When was your dog's last meal? What did he/she eat? Has your dog taken any medication today? * Yes No If you answered "yes," please list medications and time given here: Does your dog need any of the following vaccinations? RabiesDistemper/ParvoBordetellaLeptospirosisLyme Do you need a refill of heartworm prevention? Yes No If "yes," please select brand and quantity needed: 6 months12 monthsTri-Heart PlusTrifexisOther If you selected "other," please list brand here so we may order it for you, if you wish. Do you need a refill of flea/tick prevention? Yes No If "yes," please select brand and quantity needed: 3 months (Bravecto only)6 months12 monthsNexGardBravectoOther If you selected "other," please list brand here so we may order it for you, if you wish. If you need refills of any other medications, including prescription foods, please list them here. If you are a human and are seeing this field, please leave it blank. If you are a human and are seeing this field, please leave it blank. Should we treat your dog immediately after the veterinarian has performed an examination, or call you with an estimate of cost before proceeding with any diagnostics or treatment? * Please Treat Immediately Please Call First By submitting this form, you consent to pay the fees for today's medical services in full upon picking up your dog. You authorize the veterinarian and staff of Kelsey Canine Medical Center, LLC to examine your dog and provide treatment as described above. You acknowledge that the clinic hours are 7:00am-5:30pm M-F, and 7:00am-noon Sat, and agree to pick up your dog before close of business. Please try to allow at least 10 minutes to speak with the technician or veterinarian at time of discharge.