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Today:
8:00 am - 6:00 pm
Open Hours
(972) 775-2901
Phone Number
840 E Main St
Midlothian, TX, 76065
Request an Appointment
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today:2023-10-02
Patient Drop Off Form
Client Name
Patient Name
Reason for Drop-Off
Vaccinations
Problem/Sickness
Labwork
Nature of Problem:
Please Read and Check:
I understand that to effectively diagnose and treat many problems, x-rays, blood test and other procedures may need to be performed. Further, I also understand that in the event of a life-threatening condition, Midlothian Veterinary Clinic staff will make every attempt to stabilize my pet and then attempt to notify me as soon as possible
I hereby also authorize the use of such anesthetics as you deem advisable and performance of such surgical or therapeutic procedures as you deem to be indicated.
I agree to indemnify and hold Midlothian Veterinary Clinic harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.
I hereby certify that I am the owner of the above named animal or responsible for it and have the authority to execute this consent. I further certify that I will take full financial responsibility for the treatment of this pet. I understand that payment is due in full on the day of treatment unless other arrangements have been made with Midlothian Veterinary Clinic in advance.
How can you be contacted today?
Please select all that apply
Coughing
Sneezing
Vomiting
Diarrhea
Blood in stool
Straining to defecate
Eating normal
Drinking normal
Has anything about your pets diet changed in the past 4-6 weeks? (treats, food, protein source, etc.
Did your pet get into trash or people food? ( treats, food, protein source, etc. )
Could pet have been exposed to any toxins? (rat poison, chocolate, plant ingestion, refrigerant, etc.)
Is patient indoor, outdoor or both?
Is patient current on vaccines?
Yes
No
Are digital Radiographs (X-Rays) ok if recommended by Doctor?
Yes
No
Is it okay to run labwork if recommended by Doctor?
Yes
No
If necessary to treat patient, is sedation ok?
Yes
No
If yes, note approximate time pet last ate
Please leave any concerns or questions you may have here
Please leave this field empty.
Please leave this field empty.
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