Client InformationClient Name* First Last Client Phone*Client Email Patient InformationPet's Name* Breed* Age* Sex*MaleMale NeuteredFemaleFemale SpayedReason for Visit* Please select any additional procedures you wish to have performed on your pet today. Nail Trim ($16) Ear Cleaning ($26) Ear Hair Removal ($15) Express Anal Glands ($18) Microchip w/ Lifetime Registration ($40) Other Other Procedure Please list any medications you would like to pick up at your appointment today.I authorize routine imaging, blood work or labs for my pet deemed necessary by the attending doctor.* Yes No Call Prior to Would you like to list an Emergency Contact or person who is authorized to initiate treatment for your pet? Yes No Emergency Contact Name* Relationship to Client* Phone* Mobile Home Items left with pet Please note if you pet is experiencing any ailments such as vomiting, diarrhea, sneezing, coughing, lameness, etc., you have any questions or any specific concerns about the health of your pet, we encourage you to fill out the Sick Pet Admission Form to include as much detailed history as possible for our doctors to better assess your pet. CPR In the event your pet should experience cardiac or respiratory arrest while being treated today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet’s status? By consenting to this service, you are, also, acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitative efforts will continue to be performed at the doctor’s discretion.* I agree to CPR being performed in case of emergency. I elect a “Do not resuscitate” status in case of emergency. For the safety of your pet and others, we ask that all animals coming into the building be restrained by a leash or in a carrier upon arrival. Those individuals without proper restraint may request assistance upon arrival. Acknowledgements I am the owner or authorized agent for the pet described above and have the authority to initiate care by executing this consent. By signing this, I certify that I am over 18 years of age and hereby agree to make myself available by PHONE between the hours of 9:30am – 3:30 pm to aid the doctor with any questions regarding my pet’s history or symptoms. I agree to pay in full for services rendered on this date, including those deemed necessary for any medical complications or unforeseen circumstances. If for any reason there are financial restrictions associated with this visit, it is my responsibility as the owner/authorized agent to notify a staff member of such limitations PRIOR to examination or initiation of treatment for my pet. I am, also, aware that a 50% deposit of detailed treatment plan may be required prior to hospitalization or treatment of my pet. I am aware of the right to decline any services prior to them being performed and by doing so, understand a second visit may be required at an additional cost, including but not limited to additional exam fees and diagnostic charges. * I have read and agree Ownder Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. </noscript><iframe class="lazy" style='display:none;width:0px;height:0px;' src="" data-src='about:blank' name='gform_ajax_frame_8' id='gform_ajax_frame_8' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'>
