Drop Off Form

Welcome to Gully Animal Hospital! Thank you for giving us the opportunity to care for your pet! So we may provide you with exceptional service, please share a little information about you and your pet(s). Our mission is to provide the most compassionate medical care for your pets.

Address, Phone or Email Changes?

YesNo

Is your pet on any medications?

YesNo

Did your pet eat this morning?

YesNo

Was food offered?

YesNo

Has your pet had any
reaction to medications?

YesNo

Has your pet had any reaction to vaccines?

YesNo

Have you administered flea or heatworm prevention in the past 3 weeks?

If so what kind?

YesNo

HISTORY (mark any that apply)

Has your pet shown any signs of the following?

Vomiting?

Diarrhea?

Lethargic?

No appetite?

Weakness?

Coughing?

Gagging?

Scratching?

Hair loss?

Straining to urinate?

Lumps?

Shaking head?

Scooting?

Seizures?

Urinating more or less than usual

Drinking more or less than usual?

Lumping?

Weight loss or weight gain?

Bad breath?

Straining to defacate?

Panting?

CONSENT :

In the event of an emergency or if further diagnostics should be needed, we will make our best effort to reach you at the number provided below. However, should we be unable to reach you, please choose one of the following options:

I DO authorize additional treatment.I DO NOT authorize additional treatment of ANY kind without my consent, with the exception of life-saving treatments.

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