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Patient Drop-Off Form

Due to the current COVID recommendations, we have elected to use this form to streamline the drop off process. Please complete this form and let us know when you are ready for a staff member to come out to get your pet by calling (919) 261-8811. Thank you for your patience.
Client Name*
Patient Name*
Date
MM slash DD slash YYYY
Best Contact Number*
How should we contact you?
- Text
- Call
Being responsible for the above-described animal, I have the authority to grant you my consent to receive, prescribe for, treat and/or operate on my pet.
I authorize the personnel of Knightdale Animal Hospital to:
Perform bloodwork as recommended for my pet.
- Accept
- Decline
Give medication in the hospital and prescribe for home use if needed for my pet.
- Accept
- Decline
Use fluid therapy for my pet if needed as determined by the doctor.
- Accept
- Decline
Update annual vaccinations or recommended diagnostic test; e.g. heartworm, medication rechecks, Feline Leukemia testing.
- Accept
- Decline
What do you feed your pet and when was he/she last fed?
Please list the reasons why we are seeing your pet today, and any concerns you may have.
List of current medications your pet is taking.
Are there any additional concerns you would like for us to address during this visit today?
I understand a written estimate for these services will be made available upon my request and that I will provide a 50% deposit for the estimated fees.
- Accept
In an effort to maintain a flea-free hospital, if fleas are found on my pet upon admittance to Knightdale Animal Hospital, I agree to treatment with an appropriate oral or topical flea treatment to prevent spread of those parasite to other hospitalized patients. I understand I will be charged for this treatment.
- Accept
I understand that Knightdale Animal Hospital is not responsible for personal belongings that are left with your pet. We do provide towels and blankets in the cages where all patients are kept.
- Accept
While I accept that all procedures will be performed to the best of the abilities of the hospital's staff, I understand that no guarantee has been made regarding the results that may be achieved. I agree to assume financial responsibility and provide payment at the time that services are rendered.
- Accept
Electronic Signature*

Owner/Responsible Party
Date*
MM slash DD slash YYYY

Knightdale
Animal
Hospital

7527 Knightdale Blvd
Knightdale, NC, 27545
Call or Text: (919) 261-8811
Email: [email protected]

Hospital Hours
Mon - Fri: 7:30 AM – 5:30 PM
Saturday: 8:00 AM – 12:00 PM
Closed: Sundays

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