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General Drop Off

Please only use this form if you have a drop-off appointment scheduled that is not covered by the other forms (i.e. Surgery, Dentistry, and Ultrasound). If those apply, please complete that appropriate form, there is no need to complete this as well. Click here to view other forms.

"*" indicates required fields

Owner Name/Caretaker*

First

Last

Primary Contact Number*

Secondary Contact Number*

Pet's Name*

Date of Scheduled Procedure*

Reason(s) for Drop Off (*Please include all pertinent details)*

Current Diet*

Current Medications*

Did your pet eat this morning?*

Do we have permission to sedate your animal for medical procedures to be performed if deemed necessary by the veterinarian to reduce stress and fear? The cost for this is $82-102.*

I understand ALL of the following

I understand and agree to ONE of the following:*

I authorize testing and treatment as outlined on the estimate given and place NO limit on additional charges/services carried out at the doctor’s discretion.

I authorize treatment as outlined on the estimate given and approve charges up to an additional specified dollar amount (specify in the space provided below).

Please call me with a revised estimate before performing any additional procedures not outlined on the estimate given. If I cannot be reached, I authorize additional treatments deemed appropriate by the veterinarian.

Please call me with a revised estimate before performing any additional procedures not outlined on the estimate given. I understand that if I cannot be reached, my pet will receive NO treatments, except in the case of an emergency, other than those outlined on the original estimate.

If choosing option #2, please specify dollar amount:

I have reviewed the above material. I have had all my questions answered and fully understand the procedures to be performed and the associated risks.

I understand that Shiloh Animal Hospital is not staffed overnight.

Please be advised that the pick-up time will be determined by the number of procedures we have, your pet’s recovery, and your pet’s procedure. Pick-up is frequently early to mid-afternoon, although we will contact you after the procedure to schedule a more precise time.

As the owner or agent of my pet, I hereby give my consent to Shiloh Animal Hospital to perform the above said procedure(s).

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General Drop Off

I understand ALL of the following

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919-825-1000

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919-825-1000