Check In & Authorization Form

If you are planning on bringing your pet in to Guilford-Jamestown Veterinary Hospital for an appointment or boarding, please fill in this form ahead of time to make the process more efficient.

First Name *

Last Name *

Pet's Name *

Email Address *

Phone Number *

Reason for Visit: *

If necessary, do we have permission to sedate your pet? *

When did your pet last eat? *

Does your pet have any of the following symptoms? *

Diarrhea

Vomiting

Limping

Lethargy

Coughing

Itching/Scratching

Other (please specify below)

None

If your pet has any of the above symptoms, please indicate how frequently they occur: *

Is your pet on any medication we should know about? If so, please specify. *

When was the last dose of medication given?

Is your pet on monthly heartworm & flea prevention? *

Is your pet on any special food we should know about? If so, please specify. *

I authorize Guilford-Jamestown Veterinary Hospital and its staff to treat the above mentioned animal. To administer vaccines, medications, tests, surgical procedures, anesthetics, or treatments that the doctors deem necessary for the health, safety or
well-being of the above animal while it is under their care and supervision.
I am responsible for the payment of the above procedures and treatments in full at the time the animal is discharged. If
I neglect to pick the animal up within five (5) days of the written notice that it is ready for release, you may assume it abandoned. You are then authorized to dispose of it as you see fit. Abandonment does not release me of my obligation for the bill. I agree that in non-payment a finance charge will be charged and that any collection of fees or attorney fees will be paid by me.
By submitting this form, I agree to the above.

Check here to agree to the above. *

I agree.

What is your preferred method of contacting you with questions or when pet is ready to go home? *

Which form of payment will you be using? *

Comments or Questions:

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Check In & Authorization Form

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