General Drop Off Form in Katy, TX | Circle B Veterinary Hospital

Owner Name*

First Last

Patient Name*

Species*

Dog
Cat

Breed*

Sex*

(Select one)*

Neutered /Spayed
Intact

age*

What medications is your pet currently taking and when was the last time it was given? Refills?*

Is there a change in activity level?*

Yes
No

When did your pet last eat?*

Any changes to appetite or drinking?*

Yes
No

Briefly Explain

Any changes with urination or bowel movements?*

Yes
No

Briefly Explain

Has your pet been recently boarded or around other/new pets?*

Yes
No

Briefly Explain

Any known allergies or reactions to vaccines or medications?*

Yes
No

Briefly Explain

If your pet is due for a vaccine, heartworm test, or fecal exam, would you like us to proceed or would you like to be contacted first?*

Proceed
Call Firs

Which vaccines or tests?

After examination by the doctor, may we proceed with tests/treatment?*

Yes
Please call first

Best contact person and number(s) for today:*

Preferred pick up time:*

Waiting outside
Pickup time

Are there any other concerns or questions you may have?*

Yes
No

If yes, briefly explain

If there are any complications (if your pet is severely ill or has a life-threatening reaction) please select one if we CANNOT reach you for decision.*

CPR
DNR (do not resuscitate)

Payment Method*

Cash
Check
Credit Card
Care Credit

Signature*

Name

This field is for validation purposes and should be left unchanged.