PET AND CLIENT INFORMATION
Today's Date:
Client Name:
Check-in Date:
Check-out Date:
Run:
Suite:
Hospital:
Patient Information
Pet:
Age:
Breed:
Color:
Weight:
Type of Pet:
Sex:
PRESCRIPTION MEDICATION
All prescriptions must be presented in original bottles and listed below
Med 1:
Directions:
Please provide times per line. Ex. Start: AM / 12 / PM
Med 2:
Directions
Please provide times per line. Ex. Start: AM / 12 / PM
Med 3:
Directions:
Please provide times per line. Ex. Start: AM / 12 / PM
Med 4:
Directions:
Please provide times per line. Ex. Start: AM / 12 / PM
SIGNATURE
By signing below I agree that the medications and / or supplements listed above can be given to my pet according to the documented instructions on the veterinarian prescribed Rx labels or the instructions that I have provided to the St. Francis Pet Care Center staff. I understand that all medications with instructions of GIVE AS NEEDED must be approved by the attending veterinarian and that the veterinarian will perform a complete physical exam on my pet in order to determine that the medication and dosing are appropriate. I further understand that I will be responsible for an examination fee if it is completed on my pet.
Type Name as Signature: