TREATMENT FORM Owner Last Name: ____________________________ First Name: ________________________ Phone Number: ____________________ Pet Name: _____________________________ Emergency Contact: __________________________ Phone: _________________________ Please check Yes or No (Additional Fees apply): Do you want a bath for your pet? Y___ / N___ Nail Trim? Y___ / N___ Brief Ear Cleaning? Y___ / N___ Is your pet current on all vaccines? Y ___/ N ___ Is your pet current of heartworm/ flea/ tick prevention? Y___ / N___ If no, may we update your pets' vaccines today? Y___/ N___ If not, may we administer prevention today? Y___ / N___ Vaccines/ Services to be performed during your pets visit (Additional fees apply): DHLPPC ____ DHPPC___ Bordetella ____ Leptospirosis____ Rabies____ Fecal ____ Microchip____ Influenza ____ FVRCP____ Heartworm Test_____ FELV____ Sometimes a pet objects to us trying to help him/her and becomes irritated enough so that we cannot accomplish our goal. Should this occur, may we sedate your pet to complete the work? If so, there will be an additional fee for sedation. NCAH hospitalizes sick pets and if your pet is not fully vaccinated he/ she may be exposed to contagious viruses YES you may sedate NO you may not sedate Treatments To Be Performed Today: __________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Special Food or Medication: __________________________________________________________________________________________ Time Fed/Medicated: _______________________________________________________________________________________________ Additional Notes/ Comments: _________________________________________________________________________________________ Pets Belongings (Please list): __________________________________________________________________________________________ In the event of a medical emergency, I give the doctors permission to treat my pet as needed and agree to cover the fees associated with such treatment. Aggressive pets may incur additional handling fees. **Pets having treatments will be released after 4:30 p.m.** Client Signature: ______________________________________________________________ Date: __________________________ THANK YOU FOR CHOOSING NORTH CHANNEL ANIMAL HOSPITAL FOR YOUR PETS' VETERINARY NEEDS!Microsoft Word 2016