Client Check-In Form

If you have not already done so, please call the staff inside at (919) 781-5145 before you complete this form to let them know that you are here. They will assist you in completing the check-in process.

Owner/Agent of Owner Name

Owner/Agent of owner Name(Required)

Address(Required)

Date(Required)

Driver’s License #(Required)

Cell Phone

Home Phone

Email(Required)

Co-Owner/ Agent of Owner Information

Please complete the fields below IF you would like to add a co-owner.

Spouse/Co-owner's Name

Spouse/Co-owner's Phone

Select Primary Contact

Regular Veterinary Practice Name

Please write None or N/A if your pet does not have a regular veterinary practice. If your pet goes to a chain of veterinary practices (Banfield, VCA, etc) please indicate the city or street name of the practice as well.

Regular Veterinary Practice(Required)

Pet Insurance

Name

Policy Number

Did you have to ring the bell for entry?

What is the best way to reach you?

Pet Information

Name(Required)

Estimated Age(Required)

Species(Required)

Breed(Required)

Color(Required)

Gender(Required)

Spayed/Neutered?(Required)

Have you been here before?(Required)

Current on all veterinarian recommended vaccinations?(Required)

Vaccinated by a veterinarian?(Required)

Please list any chronic health problems, allergies, current prescriptions, or other special medical information of which we should be aware

I grant permission to Animal Emergency Hospital and Urgent Care to post photos of my pet and a brief description of his/her case on public access websites for educational purposes. I understand that no personal information will be disclosed.

How Did You Hear About Us?

Untitled

Are you eligible for Military discount?

Discount is available to current and Veteran members of the US Military, National Guard and Reserve. Immediate family members who reside in the same household are also eligible.

Eligible for Military discount(Required)

Additional Information

Unless you notify the veterinarian handling your case that you do not give permission, a copy of your pet's medical record will be available to your regular veterinarian.
Payment is due at the time services are rendered. We will gladly prepare a written estimate before diagnostics and treatment are performed and after the doctor evaluates your pet. A deposit is required when a patient is hospitalized.

I hereby grant permission to the veterinarians in charge of the care of the pet described above to administer any treatment or anesthetics and to perform any such operations as may be deemed necessary or advisable in the diagnosis and medical care of this pet. I certify that I have read and understand the above information. I certify that I am at least 18 years of age and accept full responsibility for payment.

Owner’s Signature(Required)

Date(Required)

Today's Date

Critical Care Authorization

If your pet has been presented in a critical or life threatening state (i.e. - respiratory distress, active seizures, not breathing/no heartbeat, unconscious, etc.), we will need to assess and stabilize your pet. In order to initiate and/or continue acute care, we will need authorization of an initial estimate of at least $700, due at time of service, to perform immediate critical care procedures. This estimate is only for initial stabilization and does not include continued care such as hospitalization, treatments, medications or follow-up care. The doctors and staff will keep you informed as best as possible while performing life-saving procedures. We will provide you with a written estimate of expected charges for continued care at that time. A deposit will be required for patients remaining in the hospital for continued care.Your signature below indicates that you have read and fully understand the above and are authorizing our doctors and staff to perform critical care stabilization.

Owner's/Agent's Name(Required)

Pet's Name(Required)

Please select one of the following options:

During emergency treatment if my pet experiences cardiac and/or respiratory arrest and the doctor deems it appropriate*

cardiac and/or respiratory arrest and the doctor deems it appropriate(Required)

I authorize resuscitation (CPR) - I am aware that this may cost an additional $800

I do not authorize resuscitation (DNR)

I am unsure which option to choose for resuscitation, so I leave it up to the veterinarian’s discretion whether or not to attempt resuscitation- I am aware this may cost an additional $800 if resuscitation is attempted

Owner’s/Agent’s Signature(Required)

After you click Submit, you will be redirected to the History Form. Please complete the History form for your pet's appointment. Thank you!

64447