Owner's Name

Pet's Name

Cell Phone

Email Address

Preferred Method of Contact

Phone Call

Text Message

Email

AUTHORIZATION FOR MEDICAL CARE

I authorize Five Oaks Animal Hospital and its doctors to perform medical treatments and diagnostic tests
that are deemed necessary to evaluate and ensure the health and well-being of my pet.

Initials

I authorize Five Oaks Animal Hospital to provide examination and diagnostic services up to a maximum of
$350 without obtaining additional authorization from me. I understand that this amount may not include
medications or other treatments prescribed for my pet to go home.

Initials

OWNER CERTIFICATION AND FINANCIAL RESPONSIBILITY

I certify that I am the owner or authorized agent of the owner of the animal described above. I hereby
give Five Oaks Animal Hospital full and complete authority to examine and treat my pet as medically
necessary within the authorization provided above.
I have read and understand this Drop-Off Authorization Form, including the hospital’s policies and my
financial responsibility for all services, treatments, medications, and diagnostic tests provided to my pet.

Name

Current Date

PET MEDICAL HISTORY FORM

Pet's Name

Species

Dog

Cat

Other

Breed

Age

Sex

Male

Female

Sterilization Status

Neutered

Spayed

Intact

REASON FOR TODAY'S VISIT

What is your primary concern or reason for bringing your pet in today?

When did you first notice the problem?

Has the problem

Improved

Worsened

Stayed the Same

Comes and Goes

Please list all medications, preventatives, vitamins, supplements, or other products your pet is currently receiving, including dose, and how often it's given.

ALLERGIES & PREVIOUS REACTIONS

Does your pet have any known allergies?

Yes

No

If yes, please list:

Has your pet ever had a reaction to a medication, vaccine, anesthesia, food, or other substance?

Yes

No

If yes, please describe:

PREVIOUS MEDICAL HISTORY

Has your pet ever been diagnosed with or treated for any of the following?

Other:

Please provide additional details or dates if applicable:

SURGERIES & HOSPITALIZATIONS

Has your pet ever had surgery or been hospitalized

Yes

No

Please list the procedure, approximate date, and reason:

Has your pet ever had a problem with anesthesia?

Yes

No

Unsure

Details

VACCINATION & PREVENTATIVE CARE

Is your pet current on vaccinations?

Yes

No

Unsure

Is your pet currently receiving flea/tick prevention?

Yes

No

If yes, which product and when was it last given:

Is your pet currently receiving heartworm prevention?

Yes

No

If yes, which product and when was it last given:

DIET & DAILY ROUTINE

What food does your pet eat?

Brand/Type

Amount & Frequency

Treats/Table Food

Any recent change in diet?

Yes

No

If yes, please explain:

HOME & LIFESTYLE

Where does your pet primarily live?

Indoors

Outdoors

Both

Other pets in the household?

Yes

No

If yes, please describe:

Does your pet have access to:

Dog Park

Boarding/Daycare

Groomer

Hunting/Farm Areas

Other Animals

Unsupervised Outdoor Areas

CURRENT SYMPTOMS

Please checked any symptoms you have noticed recently:

Other:

Anything else you would like the veterinarian to know?

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Drop-Off Authorization Form

Option 1

Complete Online

Option 2

Print & Complete

Option 3

Complete on Arrival