Option 1

Complete Online

Complete and submit the online form below with assistance from our front desk staff.

Option 2

Print & Complete

Fill out a physical copy of the form with the help of our front desk staff.

Download Form

Drop-Off Form

Pet Owner First Name *

Pet Owner Last Name *

Pet Name *

Admitted By *

Acct # *

Admission Date *

Vaccination Status *

If Vaccinations Are Vet Requested, Please Specify:

Emergency Contact Name *

Emergency Contact Phone Number *

Please give a brief summary of the reason that you are dropping your pet off with us today. *

If the doctor feels that treatment is neccesary (Please Check One): *

I authorize treatment and approve charges up to a dollar amount specified below.

Call me with an estimate before any treatment is done to my pet, but if I cannot be reached, I authporize treatment as deemed appropriate by the veterinarian.

Call me with an estimate before any treatment is done to my pet, I understand that if I cannot be reached, my pet will receieve NO treatment other than a physical exam.

If you are approving charges as selected above, what is the upper limit you are willing to approve (in dollars)?

If sedation is required for treatment (Please Check One): *

I authorize the veterinarian to do so.

I would like to be notified first.

By submitting this form, I agree that I have read and understood all of the above information. I authorize Jackson Animal Clinic to render medical care for my pet(s) as specified by my above answers. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that payment in full is required prior to discharge of patient from Jackson Animal Clinic.

Spam Blocker

Drop-Off Form

Option 1

Complete Online

Option 2

Print & Complete

Drop-Off Form

New Patients Welcome