Drop Off Questionnaire

Client First and Last Name

Email

Contact Number

Street Address

Street Address Line 2

City

State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Patient Name

Breed

Sex SexMaleFemale

Age

Color

Markings

TermsI do hereby certify that, I am the owner (or duly authorized agent for the owner) of the animal described above, and I do hereby give Hallie Ray Moore, DVM, her agents, servants and/or representatives full and complete authority to perform any procedure that, at her discretion, may be useful to promote the health of the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release.

Please describe the problem(s) with your pet

How long have you noticed the problem?

What medications is your pet on?

TermsBy signing below, I hereby grant Oak Forest Veterinary Hospital permission to take photographs of myself and/or my pet, and to publish those photographs for any lawful purpose, including, but not limited to, their website, social media accounts, and promotional materials, either digital or in print, in perpetuity. I also grant permission to use my name and/or my pet’s name.

By signing this document I authorize Oak Forest Veterinary Hospital to edit, alter, share, remix, tweak, build upon or in any way alter the photograph(s) mentioned above. I also waive any rights of privacy or compensation associated with the use of my or my pet’s image(s) and name(s) for the personal or commercial purposes outlined above.

Name

Signature Date