Drop Off Form — Goose Creek Pet Hospital

Drop Off for Treatment Authorization

Since you will not be present for the visit, please fill out this form entirely. If we have any further questions, we will contact you on the given phone number.

Pet Name

Owner Name

First Name

Last Name

Phone

(###)

###

####

How do you prefer to be contacted?

Phone Call

Text Message

Either is Fine

Your pet will be seen by the FIRST available veterinarian for their current condition, unless specific doctor is requested, if available. *Please note, your pet may be waiting additional time to be seen by requested doctor.

Yes, my pet can be seen by the first available veterinarian.

I would like my pet seen by my requested veterinarian.

Please list your preferred doctor, if any:

Reason for Drop Off:

Please select the option that bests fits your needs.

Please list all concerns/symptoms and their duration:

Previous Medical Conditions (list none if there are none):

Please list any current medications, dosage, and when they were last given:

Please list your pet’s diet and time of last meal:

Possible procedures to be preformed: Exam ($65), Bloodwork ($85- $285), Radiographs ($90- $305), Sedation ($96- $200)

I hereby authorize the veterinarians and staff of Goose Creek Pet Hospital to administer treatment as necessary and to preform procedures diagnostically and/or therapeutically. I understand that there is no guarantee of successful treatment. I assume all financial responsibilities for all charges incurred and agree to pay such charges at the time of release.

I have been presented and signed an estimate at the time of drop off. If the ideal treatment plan changes, or if the cost exceeds the presented estimate:

Proceed with all necessary treatments/testing without called approval.

Proceed with all necessary treatments/testing, but do not exceed $200 above presented estimate without my approval.

Do not preform any additional treatments without my approval. I understand this may mean my pet has to come back on a later date if I cannot be reached.

Your pet must be picked up by 5pm today (unless other arrangements have been made by the veterinarian/hospital staff).

Please type your name to complete this form.

Please note, this will act as your signature to approve the above form