Name*Pet(s) Name(s)*Email* What type of animal will be staying with us?*CanineFelineTo 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?*YesNoAppetite is normal?*YesNoWeight Loss?*YesNoCoughing?*YesNoActive?*YesNoListless/Lethargic?*YesNoDiet Change?*YesNoIs your pet on Heartworm preventative?*YesNoAny vomiting?*YesNoIf yes, how often?Any diarrhea?*YesNoIf yes, how often?Acting like they are in any pain?*YesNoIf yes, how often?Any bleeding?*YesNoIf yes, how often?Any lameness?*YesNoIf 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*ApprovedDeclinedBloodwork*ApprovedDeclinedTranquilization*ApprovedDeclinedDrop 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 CAPTCHAEmailThis field is for validation purposes and should be left unchanged.