Curbside Questions

I am in this vehicle: *

(Please list the model and color.)

Best phone number for today's appointment: *

(The veterinarian and technician will use this number to communicate with you through the appointment.)

Email *

Patient's Name *

Patient's Species *

Canine
Feline
Other

If 'Other', please specify: *

Owner's Name *

First

Last

Appointment Date/Time *

Date

Time

Primary Reason for Appointment / Concern (please be as detailed as possible) *

Patient's Energy Level

Normal
Increased
Decreased

Please list the medications your pet is currently taking:

Do you need refills of any of these medications?

Yes
No

If you need a medication refill, please list which medications:

Do you need refills on any prescription pet food?

Yes
No

If you need a prescription pet food refill, please let us know which kind:

Patient's Appetite

Normal
Increased
Decreased

What is frequency of eating?

What type of food?

Drinking/Water Intake

Normal
Increased
Decreased

Is the patient coughing?

Yes
No

If yes, for how long?

Is the patient sneezing?

Yes
No

If yes, for how long?

Is the patient vomiting?

Yes
No

Is the patient experiencing diarrhea?

Yes
No

If yes, for how long?

What you are visiting for? *

Please upload any relevant records or photos below:

Click or drag files to this area to upload. You can upload up to 5 files.

I verify that I am the true and legal owner (or authorized agent for owner) of the above named pet and authorize he/she to receive treatment as deemed medically necessary by my veterinarian. I authorize the use of sedation and/or other medication in case of emergency and understand medical personnel will be employed at the direction of my veterinarian.

I understand and have been advised of the risk associated with any possible medical or surgical intervention or episode, even in apparently healthy animals and have discussed my concerns with my veterinarian and/or nurse. I understand that some medical intervention may not be previously anticipated and I hereby consent to and authorize the performance of such altered and/or additional procedures for the safety of my pet.

I agree to be responsible for any charges incurred while my pet is in the care of Tavares Crossroads Veterinary Clinic and understand payment is due at the time of discharge from the TCVC. I understand that staff will not be tending to my pet overnight, and may need to be transferred for further hospitalization in case of emergency.

I have read and understand the terms and conditions set forth above. *

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Curbside And Drop Off Check In Form Tavares Crossroads Veterinary Clinic Tavares FL

Curbside Check-In Form

Curbside Questions

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