Drop-off Form

FAMC DROP-OFF CONSENT FORM

* Indicates required field

Name *

First

Last

Pet's Name *

Reason for visit and any questions you have for the veterinarian: *

Please list all of your pet's medications, supplements and flea control *

Please tell us what food your pet eats. How is their appetite? *

Any changes in water consumption? *

Are urination & defecation normal? If not, please describe what is going on. *

Any vomiting or diarrhea? If yes please describe what is going on. *

Any changes in weight? *

Any coughing or sneezing? If yes, please describe what is going on. *

We love giving out treats. Is there anything your pet can't have while with us? *

Please select below how you wish us to proceed if any problems are found with your pet, or if any develop while your pet is in our care.

Choose One: *

Any tests/treatments deemed necessary for my pet. Any tests/treatments deemed necessary for my pet, up to chosen dollar amount. Do not perform any tests/treatments after the exam until you have spoken with me.

Chosen dollar amount: *

If sedation/anesthesia is required: I hereby authorize Fidalgo Animal Medical Center to perform anesthesia, treatment and/or surgical procedures as deemed necessary for my pet. I understand the nature of the procedure and that there may be risk involved. No guarantee has been made as to the result or cure*

Select One *

Your pet will receive an examination while in our hospital. Hospitalization fees may apply.

If fleas or flea dirt are present on your pet, we will apply a quick acting Capstar flea treatment ($11.00).

I affirm that I am the owner or agent of the animal names above and I am over 18 years of age. My electronic name entry herein constitutes my legal signature and authorizes Fidalgo Animal Medical Center to examine my pet. I understand the doctor will contact me after she/he has examined my pet, to discussed their findings and recommendations. I authorize my pet to leave my custody and enter the clinic in the care of a clinic team member. Should life-saving emergency care be needed, it will be performed unless discussed prior with your care team.

Name *

First

Last

Vehicle make/model/color: *

Phone number for the doctor to call: *

Photo Release *

I hereby grant FAMC permission to take photos and/or video of my pet and/or myself, and to publish those images,with or without my name and/or my pet’s name, 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 waive any rights of compensation associated with the use of my/my pet’s image(s) and name(s) for the purposes outlined above.

Submit

FAMC DROP-OFF CONSENT FORM

FIDALGO ANIMAL MEDICAL CENTER

office hours

In Case of Emergency

3303 Commercial Ave
Anacortes, WA 98221
FAMC@FIDALGOVETS.COM

Our Partners in care

FAMC DROP-OFF CONSENT FORM

FIDALGO ANIMAL MEDICAL CENTER

office hours

In Case of Emergency

3303 Commercial AveAnacortes, WA 98221FAMC@FIDALGOVETS.COM​​

Our Partners in care

3303 Commercial Ave
Anacortes, WA 98221
FAMC@FIDALGOVETS.COM