Drop Off Form Owner's Name * First Name Last Name Pet's Name * Phone Number to Call to Reach You Today: * (###) ### #### What Food Does Your Pet Currently Eat? * Is Your Pet Currently Exhibiting the Following? * Check any that apply. Vomiting Diarrhea Coughing / Gagging Weakness Increased Thirst Weight Loss Hair Loss Itching Sneezing Eye Discharge Frequent Urination Blood in Urine Lameness Difficulty Urinating Odor / Discharge from Ears Other Concerns Please Describe in Detail. * i.e. Frequency, Duration. As the owner of the pet, I hereby give permission to perform the following tests: * Any animal with fleas or flea dirt will be treated at the owner’s expense. If your pet is not up to date on vaccines, and Dr. Farris deems it appropriate to vaccinate, they will be made current while in the clinic. Bloodwork / Urinalysis / Fecal X-Rays Sedation, if necessary Other tests as the Doctor deems necessary Date * MM DD YYYY Signature of Owner or Agent * If completing digitally, please type your name. Thank you for submitting our Drop Off Form. We have received it and look forward to seeing you! If you have any questions, please feel free to contact us by calling 859.272.4364 or emailing fayettevet144@gmail.com.