St. Francis Animal Rescue Consent Drop-off Form Date of Appointment(Required) MM slash DD slash YYYY Pet's Name(Required) Please also list any other names the pet may be known asWho is your pet seeing today?Please SelectDr. Ronald HamiltonDr. Brittany MathesDr. Shelby HixonDr. Michelle NewkirkA TechnicianAuthorizing Rescue Contact Name(Required) Kathy Jen Laura Other Other(Required) Contact phone number of responsible party of pet while in the hospital today?(Required)Email(Required) Foster/Caretaker Contact Phone(Required)Foster/Caretaker Contact Name(Required) First Last Preferred Method of Contact?(Required) Call Text I am the foster/caretaker for this animal and thus by filling this form out, I acknowledge that the appropriate St. Francis agent has been notified and granted me approval for all treatments and procedures to be performed on this animal?(Required) Please initial to confirmWhat is the sex of the pet?(Required) Male Female I Am Not Sure Reason for pet's visit today?(Required)If surgical, please list surgery type (i.e. Spay, Neuter, Dental Cleaning, Mass Removal etc.)If visit is for a sickness, how long have the symptoms persisted? Is this a TNR animal – meaning will this animal truly be released after procedure?(Required) Yes No Unsure Please select all that apply to the pets medical condition Problems eating/drinking Diarrhea Vomiting Lethargy Limping Itching Loss of Appetite Other Other(Required) Approved for any lab work necessary for treating animals condition?(Required) Yes No Contact the authorizing rescue contact before running any labwork out of normal protocls. Ear notch?(Required) Yes No Unsure Pain Relief Medications for adult/pregnant animals?(Required) Yes No Unsure Which vaccination(s) would you like us to give your pet today? Please click on the Add button to enter if more than one vaccine is needed(Required) Rabies Fvrcp None Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given and how long you have been giving them:(Required)Are there records to provide to us from any other veterinarian visit that was not to our hospital?(Required) Yes No If so, please make sure we have copies before the visit/procedure.Will an E-Collar be needed?(Required) Yes No Please indicate if instructions on usage will be needed to help avoid suture site infections.(Required) What time did the pet last eat?(Required) Do you want your pet microchipped today?(Required) Yes No In the below field, please indicate if you 1. have been giving any medications outside of the Veterinarian's directions and if so, for how long, 2. What have you been doing in accordance to the rescue protocol – deworming, vaccinations, etc.(Required)If no, please notate N/AI verify that I am the owner (or authorized rescue agent) of the above named pet and authorize treatment to be performed by Gulf Coast Veterinary Center. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.(Required)Sign hereCAPTCHA Δ
