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Drop-off Exam Form

Drop-off Exam Form

Drop-off Exam

Step 1 of 8

12%

Date*
MM slash DD slash YYYY
Your Name*
First Last
Your Pet's Name:*
Pet's age:*
Pet's Sex:*
Species:*
Reason for the exam:*

Is your pet allergic to any medications that you're aware of (please indicate the name of the medication if applicable)?:*
Currently taking medications? Dosages?:
Heartworm Prevention
Is your pet on heartworm prevention?:
- Yes
- No
If yes please indicate the brand and when it was last given:
Canines: Date of last heartworm test:
MM slash DD slash YYYY

Feline FeLV/FIV Test
Felines: Has your pet had a FeLV/FIV test?:
- Yes
- No

Flea and Tick Prevention
Is your pet using flea and tick prevention?*
- Yes
- No
If yes please indicate the brand and when it was last applied:

Observations
Coughing or sneezing?:*
- Yes
- No
Vomiting or diarrhea?:*
- Yes
- No
Change in appetite or thirst?:*
- Yes
- No
Observed/felt lumps or bumps?:*
- Yes
- No
Observed scratching or licking?:*
- Yes
- No
Soreness or stiffness after resting or exercise?:*
- Yes
- No
Change in outside or litterbox habits?:*
- Yes
- No
Observed/felt change in weight?:*
- Yes
- No
Behavior changes?:*
- Yes
- No

Diet
What food are you feeding your pet?:*
Frequency of feeding per day (please be specific):*
- x1 a day
- x2 a day
- x3 a day

Services Requested
Please specify requested services:
- Vaccines
- Lab Work
- Nail Trim
- Anal Glands
- Microchip
- None of the above
Anything else you'd like us to know? :

Consent*
I am providing my consent to the outlined services.
By providing my name I give Queenstown Veterinary Hospital my authorization for all noted Drop-Off Exam requests.*
Phone number where I can be reached:*
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Schedule an appointment
Hours of Operation

Monday-Friday: 7:30am – 6pm
Saturdays: Closed
Sundays: Closed

*Closed on all major holidays

Please contact our main office at (410) 827-6776 to make an appointment today.

Hours of Operation

Monday-Friday: 7:30am – 6pm
Saturdays: Closed
Sundays: Closed
*Closed on all major holidays

105 4-H Park Road
Queenstown, MD 21658

Newsletter

Be first in the loop when it comes to events and pet health tips! Get our latest news straight to your inbox.

Email*
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Quick Links and Resources

Annapolis Office: Western Shore Veterinary
Military Discount
Online Pharmacy
New Patient Form
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