Please Note: We will be closing early at noon on Tuesday, December 24th and will be closed on Wednesday, December 25th in observance of Christmas!

Online forms

Drop Off Form

Save time during your next appointment! Complete your required forms online from any device at any time before your visit.

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Drop Off Form

Thank you for entrusting Cypress Veterinary Clinic for your pet’s care! Please fill out our drop off form in its entirety. We look forward to meeting you!

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Reason for today's visit: (please select all that apply) *

Wellness exam / vaccines
Illness
Injury

Please explain illness: *

Please explain injury: *

What would you like doctor to know about your pet's health? *

What would you like doctor to know about your pet's illness? How long have they been dealing with the illness? *

What would you like doctor to know about your pet's injury? When did injury occur? *

Pet's Name *

How is your pet's appetite? *

Normal
Increased
Decreased

What type of food do you feed? *

When was the pet's last meal? *

How is your pet's water consumption? *

Normal
Increased
Decreased

Has your pet been vomiting? *

Please explain.

How is your pet's stool? *

Normal
Abnormal

Please explain.

How is your pet's urination? *

Normal
Increased
Decreased
Painful
Straining

Has your pet shown any sign of:

Bad breath
Behavior changes
Breathing problems
Coughing
Depression
Difficulty with rising, sitting, jumping, or stairs
Excessive sleeping
Gums bleeding
Limping
Loss of balance
Restlessness
Scooting
Scratching / chewing
Shaking head
Skin masses/lesions
Sneezing
Weight changes
Other

Please explain your pet's bad breath. *

Please explain your pet's behavior changes. *

Please explain your pet's breathing problems. *

Please explain your pet's coughing issues. *

Please explain your pet's depression. *

Please explain your pet's difficulty moving. *

Please explain your pet's excessive sleeping. *

Please explain your pet's bleeding gums. *

Please explain your pet's limping. *

Please explain your pet's loss of balance. *

Please explain your pet's restlessness. *

Please explain your pet's scooting. *

Please explain your pet's scratching and chewing. *

Please explain your pet's head shaking. *

Please explain your pet's skin masses and lesions. *

Please explain your pet's sneezing. *

Please explain your pet's weight change. *

If Other, please explain *

Is your pet on heartworm prevention? *

Flea prevention? *

Current on vaccinations? *

Is your pet on any medications? *

If yes, what medications and when were they last given?

Is there anything else needed while pet is here (check all that apply)? *

Nail Trim
Heartworm test
FeLV/FIV testing
Check ears
Clean ears
Express anal glands
Fecal testing
Update vaccines if possible (Dr. Discretion)
Microchip
Blood work
Refill of preventions
Other

Please specify other service *

(Feline Only) Does your pet go outside?

I understand if my pet is found to have fleas, he/she will be treated at my expense. *

I have read and understand.

Do we have your permission to sedate/anesthetize your pet if necessary in order to perform an exam, diagnostic test, or agreed upon surgical procedure? *

I understand that there may be restrictions to my pet’s activity and agree to follow the recommended post-operative instructions after this procedure. *

I have read and understand

I understand that CVC recommends current blood work (4 weeks or less) for any procedure requiring anesthesia regardless of age. *

I have read and understand

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. Subject to my directions above, I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. *

I have read and understand

The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my pet is released from the hospital. *

I have read and agree

Today's Date *

Comment

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Address

753 West Cypress Street
Kennett Square, PA 19348



Contact

E: [email protected]
P: 1-484-734-0686

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Hours

Mon, Tues, Wed, Fri: 8 am – 6 pm
Thurs: 8 am – 5 pm
Sat & Sun: Closed

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