Diabetic GlucoseCurve Drop-off Form

Make the most of your next appointment by saving time! Before your appointment, fill out your diabetic glucose curve drop-off form from any device at any time.

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Diabetic Glucose Curve Drop-off Form

Client's name *

First

Last

Email *

Pet's name

Ultrasound Procedure

The phone number where you can be reached TODAY is *

Note: In case of an emergency and/or prior to additional procedures, you will be contacted by telephone. Please keep your phone with you.

Other phone number where you can be reached TODAY is

To help us provide the best care, please complete the following:

Insulin Type

Insulin Dose

Usual time/schedule of insulin

Time of last dose of insulin

Food Type

Food Amount

Treats or other items fed to your pet

Usual time/schedule of food (including treats)

Time of last meal

Describe your pets drinking & urination habits

What is your pet's comfort level, on a scale of 1-10, with 10 being the most comfortable?

Describe any vomiting, diarrhea, coughing or sneezing?

Describe your pet’s activity level

Describe any weight change (loss/gain) that you have noticed?

List any other prescription medications, flea/heartworm/tick prevention or supplements your pet is currently taking (please include frequency and dose given [ie: 1 tablet twice a day])

Describe any known allergies

Please acknowledge the following Information:

I authorize Rancho San Carlos Pet Clinic is authorized to perform blood draws for glucose evaluation (charge per glucose). I certify that I am the owner, or authorized agent for the owner, of the above pet. I authorize the doctor on duty and assistants to perform the above described procedures including administration of sedatives and/or anesthetics, as well as any necessary and appropriate medical, surgical, nursing, diagnostic, and/or emergency care for the above pet. I understand that Rancho San Carlos Pet Clinic is not a 24 hour hospital. Should an overnight stay be necessary, direct observation will not be available. If the above pet needs observation we recommend transfer to a 24 hour emergency hospital. understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital. All pets must be free of parasites including fleas, ticks and intestinal parasites. Pets with Fleas will be given Capstar in accordance to our Flea Free Hospital protocol (Owner is responsible for additional fees). I understand the payment in full for medical services provided is due at the time of discharge of my pet and that I may be asked to leave a deposit prior to the start of the medical services. I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may have my permission as follows:

Rancho San Carlos Pet Clinic is authorized to perform all treatments as deemed necessary without regards to cost.
Rancho San Carlos Pet Clinic is authorized to perform treatment as deemed necessary up to $____________
Rancho San Carlos Pet Clinic should not perform any medical care except life saving measures (CPR/life sustaining procedures can range from $100 -$500, or more depending on the situation).

CPR Consent: Some patients requiring ultrasound have illness. In the event of a catastrophic emergency, please elect what life-saving measures you would like performed so that we may be in accordance with your wishes: (these are at additional cost)

Do NOT perform CPR on my pet
Basic life support and CPR measures (chest compressions, artificial respiration)
Advanced life support and CPR measures (IV medications, fluids, etc)

We place the highest priority on ensuring you feel comfortable with the plan for your pet’s care and fully understand the authorizations below above giving your consent. If you have any questions or need clarification on any of the choices, please contact the hospital so a medical team member can review the form with you prior to completing it. As always, thank you for entrusting us with your pet’s care!

Signature *

Clear Signature

Print name *

First

Last

Date *

Diabetic GlucoseCurve Drop-off Form

Diabetic Glucose Curve Drop-off Form

To help us provide the best care, please complete the following:

Please acknowledge the following Information:

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