Name* Pet(s) Name(s)* Email* What type of animal will be staying with us?* Canine Feline To the best of your knowledge, is your pet up to date on his/her shots?* Rabies (Canine/Feline) Bordetella (Canine) DHLP-PV (Canine) * HW Test (Canine) Influenza Combo (Canine) FVR-CP (Feline) * FELV (Feline) FIV-FELV test (Feline) Reason for Visit?*Duration of problem?*What phone number(s) may we reach you at today?*To help us better evaluate your pet in your absence, please answer the following:Water intake is normal?* Yes No Appetite is normal?* Yes No Weight Loss?* Yes No Coughing?* Yes No Active?* Yes No Listless/Lethargic?* Yes No Diet Change?* Yes No Is your pet on Heartworm preventative?* Yes No Any vomiting?* Yes No If yes, how often? Any diarrhea?* Yes No If yes, how often? Acting like they are in any pain?* Yes No If yes, how often? Any bleeding?* Yes No If yes, how often? Any lameness?* Yes No If yes, how often? Often bloodwork and x-rays are needed to diagnose what a routine visual exam does not. **These have additional charges**X-rays* Approved Declined Bloodwork* Approved Declined Tranquilization* Approved Declined Drop Off Requirements 1. All animals must be current on all required vaccinations. 2. All animals must be free of external and internal parasites (ticks, fleas, etc.), or they will be treated at the owner’s expense. 3. WSVC has my permission to do whatever necessary should an emergency arise. 4. Pets may be picked up between 2:00 pm – 5:45 pm, Monday – Friday. No Exceptions! 5. Any towels or personal items should be marked with the last name. This will ensure that if they become soiled, we are able to identify them after washing. (When items become soiled, it is unsanitary for us to keep without washing them.)Signature required at time of drop off* First Last CAPTCHANameThis field is for validation purposes and should be left unchanged.