Drop Off Form

What concerns are you coming in for? *

How long ago did this problem start? *

Since the problem started have things gotten better, worse, or stayed the same? *

Has a similar problem happened in the past? *

Yes No

Do the doctors have permission to preform diagnostic tests? *

Yes No I want a call before any tests

I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the pet described above. I authorize the doctor and assistants to perform the procedure(s) listed above, including administration of pain relief medications, sedatives, and/or anesthetics, as well as any necessary medical, radiological, surgical, nursing, diagnostic, and/or emergency care for the pet. I have been advised as to the nature of the procedures and the potential risks. I also understand that no guarantee of successful treatment can be made and assume full financial responsibility.

I agree to hold Cheyenne West Animal Hospital harmless, in the absence of negligence, from and against any and all liability arising out of the performance of any of the procedure(s) referred to above. I have been informed that Cheyenne West Animal Hospital is not staffed 24 hours a day. I understand that if my pet requires overnight supervision post-surgically, or hospitalization, my pet will be referred to the appropriate emergency hospital.

Medical Drop-Off Form

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Cheyenne West Animal Hospital

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