Patient Drop-Off Form

Client Information & Consent
Who will be dropping your pet off with us for their appointment?

First Name Last Name
Is this person the primary contact for updates and communications while your pet is with us during the day?

Yes No
If no, please provide the name of the primary contact person.
Phone Number

Area Code Phone Number
May we text you?

Yes No
Requested pick up time (cannot be guaranteed)

: Hour Minutes AM/PM Option
Would you like an estimate of costs for your pet's appointment with us?

Yes No
In the event that further diagnostics are needed, or in an emergency, we will make our best effort to reach you at the phone number provided. However, should we be unable to reach you, please choose one of the following:

I DO authorize additional diagnostics or treatment without my verbal consent I DO authorize additional diagnostics or treatment without my verbal consent, up to amount indicated below* I DO NOT authorize additional diagnostics or treatment without my verbal consent
*I authorize additional diagnostics or treatment for my pet up to:
$
I understand that if I decline additional treatment, Highland Park Animal Hospital cannot legally continue diagnostics or treatment other than what I approve on my patient consent form at time of drop off. If I authorize additional treatment, I understand that I am fully responsible for any charges incurred and agree to pay in full at the time services are rendered.
Pet owner or authorized agent, initial below.
Should be Empty:

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Patient Information