Drop Off Admission Form

If you have called and scheduled a drop off appointment for your pet, please take a moment to answer the following questions and submit your answers before you bring your pet for admission. The check in process takes between 10 and 15 minutes. To save some time at check-in, please answer as many questions as you can, in as much detail as you can. If you have any questions while completing this form, we will be happy to answer them when you arrive with your pet. Check in time for admission is between 7:45am and 9:30am, we encourage you to bring your pet for check-in as early as possible before 9:30 am. Our phones are on between 8:00am and 5:00pm, mon-fri and 8:00am to noon on sat. Please call on us at 504-866-6316 if you have any questions.

Your First & Last Name*
Please provide your first and last name
Your Email Address*
Enter Email
Best Phone Number to reach you*
Best Phone Number to reach you
Pet's Name*
Date of Drop Off Appointment*
The date you have scheduled to drop off your pet. *An appointment must be scheduled PRIOR to submitting this form. Please call 504-866-6316 to schedule an appointment BEFORE submitting this form.
Date Format: MM slash DD slash YYYY
Do you have a specific time you need your pet ready to be picked up?*
Please indicate pickup time needed XX:XX pm. All patients must be picked up before our 5:00pm closing time.
Name and Phone# of Primary Person to Call on Date of Drop Off:*
Please give us the name and phone number of the person the Doctor should call after examining your pet (It is imperative that we be able to reach this person):
Name & Phone# of Secondary Person to Call on Date of Drop Off:*
Please give us the name and phone number of another person the Doctor can call and speak to about your pet, should we not be able to reach the Primary Person above.
Preferred Veterinarian:*
Please select
- First Available Veterinarian
- Dr. Erica Brasher (off Friday)
- Dr. Brian Hill (off Thursday)
- Dr. Emily Lemann (off Weds, some Fridays)
- Dr. Sharon Schmidt (off Monday)
- Dr. Mandy Walkenhorst (off Tues, and Weds in pm)
Is your pet experiencing any of the following?*
Please check ALL that apply
- Vomiting
- Diarrhea
- Loose Stool
- Constipation
- Scooting
- Coughing
- Sneezing
- Scratching
- Shaking Head
- Sores or Scabs
- Increased Urination
- Decreased Urination
- Straining to Urinate or Defectate
- Increased Thirst
- Decreased Thirst
- Increased Appetite
- Decreased Appetite
- Limping
- Difficulty Rising
- Weight Gain
- Weight Loss
- Lethargy
- None of the Above
Reason for Exam:*
Please be as specific as possible, and provide as much information and detail as you can
Any additional services you would like performed during exam:*
Please check all that apply
- Laboratory Services (Blood Work/Urine Tests)
- Radiographs (X-rays)
- Nail Trim
- Anal Gland Expression
- Avid Microchip
- Clean Ears
- Sanitary Shave
- Other (please indicate below)
- None
Additional service(s) requested, not listed above:
What is your pet's usual diet?*
Please tell us the name of pet food you feed, whether it is dry or canned food, and how much you feed, and how often. Please also include what type of treats your pet eats.
If your pet is a cat, does it go outside or live with any other housecat that goes outside?
- Yes
- No
- Unknown
What Heartworm Prevention does your pet currently take?*
Please select
- Not currently on Heartworm prevention
- Sentinel
- Trifexis
- Revolution
- Heartgard Plus
- Other
If on, date Heartworm Prevention last given/applied?
Date
Date Format: MM slash DD slash YYYY
What Flea Prevention is your pet currently on?
Please select
- Not currently on a flea prevention
- Nexgard
- Advantage
- Revolution
- Bravecto
- Other
If on, date flea prevention last given/applied?
Date Format: MM slash DD slash YYYY
Please list below all of Medications and/or Supplements your pet is currently taking:
Please list names of drugs, dosing nstructions & when he/she last received a dose
Do you need a refill of any medication(s) when you pick up your pet?
Please list which medication or supplements we can refill for you:
Consent for Treatment
Authorization
Authorization: By completing the above information and selecting this authorization, I hereby certify that I am the owner, or duly authorized agent of the owner of the animal described above and that I do hereby give Maple Small Animal Clinic, its veterinarians, agents and/or representatives full and complete authority to perform the treatments requested. I understand that if an examination is performed a doctor will contact me to discuss recommended diagnostic tests and/or treatments if recommended. I accept full responsibility for all tests and treatments that I requested above or verbally authorize during my conversation with the doctor. I understand that payment is due when my pet is discharged. I further understand that if evidence of fleas is found on my pet during examination, a dose of flea prevention will be administered at my expense.
Photos or Records you would like Doctor to see
Drop files here or

Accepted file types: jpg, gif, png, pdf.
If you have photographs or records you would like to share with the doctor, please upload them here.

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	8:00am – 12:00pm
Sunday	Closed

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Drop Off Admission Form