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Drop Off Form

Pet's Name: [esigtextfield name="esig-sif-1610127261278" class="form-control" verifysigner="undefined" size="undefined" label="Your Pet's Name" displaytype="plaintext" required="1" ]

Owner's Name: [esigtextfield name="esig-sif-1610127273497" verifysigner="undefined" size="undefined" label="Your Name" displaytype="plaintext" required="1" ]

Drop-Off Date: [esigdatepicker label="" name="esig-sif-picker-1610127298713" verifysigner="undefined" mindate="" maxdate="" displaytype="plaintext" readonly="1" required="1"]

Reason for visit: [esigtextfield name="esig-sif-1610127112926" verifysigner="undefined" size="undefined" label="Reason for visit" displaytype="plaintext" required="1" ]

I can be reached at: [esigtextfield name="esig-sif-1610127318715" verifysigner="undefined" size="undefined" label="Your Phone Number" displaytype="plaintext" required="1" ]

When did your pet eat last? [esigtextfield name="esig-sif-1610127774688" verifysigner="undefined" size="undefined" label="When did your pet east last?" displaytype="plaintext" required="1" ]

Medications: [esigtextfield name="esig-sif-1610127811604" verifysigner="undefined" size="undefined" label="Medications" displaytype="plaintext" required="0" ]

Refills: [esigtextfield name="esig-sif-1610127909951" verifysigner="undefined" size="undefined" label="Refills" displaytype="plaintext" required="0" ]

Estimate Provided? [esigtextfield name="esig-sif-1610127983260" verifysigner="undefined" size="undefined" label="When did your pet east last?" displaytype="plaintext" required="0" ]

Eating: [esigradio name="esig-sif-1610127204059" label="" display="horizontal" verifysigner="undefined" labels="Normal=&Increased=&Decreased=" required="1" ]

Drinking: [esigradio name="esig-sif-1610127348492" label="" display="horizontal" verifysigner="undefined" labels="Normal=&Increased=&Decreased=" required="1" ]

Urination: [esigradio name="esig-sif-1610127542045" label="" display="horizontal" verifysigner="undefined" labels="Normal=&Increased=&Decreased=" required="1" ]

Bowel Movements: [esigradio name="esig-sif-1610127593843" label="" display="horizontal" verifysigner="undefined" labels="Normal=&Increased=&Decreased=" required="1" ]

Activity Level: [esigradio name="esig-sif-1610127636414" label="" display="horizontal" verifysigner="undefined" labels="Normal=&Increased=&Decreased=" required="1" ]

Vomiting: [esigradio name="esig-sif-1610127673909" label="" display="horizontal" verifysigner="undefined" labels="Yes=&No=" required="1" ]

Diarrhea: [esigradio name="esig-sif-1610127724015" label="" display="horizontal" verifysigner="undefined" labels="Yes=&No=" required="1" ]

By signing below I understand that my pet must be free of external parasites such as fleas and/or ticks. If my pet is found to have such parasites, he/she will be treated accordingly at the owner’s expense.I understand that my pet must be up to date on needed vaccinations such as rabies, distemper, and bordetella in order to be hospitalized for any period of time at Lakeside Animal Hospital. Otherwise, my pet will be treated at my expense for the reason listed above. I understand that signing this form I grant Lakeside Animal Hospital to receive, prescribe for and perform treatment on my pet. If ever more testing or diagnostics are recommended to efficiently care for my pet I understand that Lakeside Animal Hospital will do all they can to contact me and receive verbal approval to perform such treatment at the owner’s expense.

[esigtodaydate name="esig-sif-today-1610128399318" verifysigner="undefined" displaytype="plaintext"]

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Timestamp

Audit

January 8, 2021 5:29 pm EDT

Drop Off Form Uploaded by Sherry Burgess - christina@jonroc.com IP 73.55.191.4

January 13, 2021 12:38 pm EDT

Document owner christina@jonroc.com has handed over this document to manager@lakeside.vet 2021-01-13 12:38:26 - 73.55.191.4