Client Information Form Client Information Form Please complete this form for faster processing prior to your visit. Have you been to this hospital before? Yes No Owner Name * Owner Name First First Last Last Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Cell Phone * Home Phone Email * Pet Name * Pet Species * DogCatOther Pet Species Pet Breed * Pet Color * Sex * Male Female Neutered/Spayed? * Yes No Age * Reason for this visit * Allergies, special problems, medications: Date of last rabies vaccine * Regular Veterinarian * Clinic Name * Hospital Consent Form I am the owner or agent of the owner of the above described animal(s) and have the authority to execute this consent. I hereby consent and authorize performance of the procedures or operations as explained to me by Veterinary Emergency Services. I understand that no one under the age of 18 can authorize services. * I consent to the above Emergency Veterinary Procedures I understand that during the performance of the foregoing procedure (s) or operation (s), unforeseen conditions may be revealed that necessitate an extension of foregoing procedure (s) or operation (s) or different procedure (s) or operation(s) than those set above. Therefore, I hereby consent to and authorize the performance of such procedure (s) or operation (s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I authorize the use of appropriate anesthetics and other medication and I understand hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure (s) or operation (s) and the risks involved. I realize that results cannot be guaranteed. * I consent to the above Payment is Due at the Time Services are Rendered Which method of payment will you be using? We do not accept checks. Cash MC/Visa Discover American Express CareCredit If my account becomes delinquent, I understand that I am responsible for all expenses, including an interest charge of 18% on the unpaid balance, attorney fees and all court costs. I have read and understand the foregoing. I authorize and consent to the treatment required and the terms contained herein. * Clear Date * If you are human, leave this field blank. Submit Appointment Request Conveniently book appointments anytime using the form below and we'll email you a confirmation. If you prefer to call, view our phone number, hours, address and directions by clicking here: Contact Us Request AppointmentRequest AppointmentPlease complete this form to request an appointment. We will schedule your reservation and email you or call to confirm your appointment booking. If you have not received confirmation within one business day, please contact us. Required sections are marked with a red * asterisk.First Name*Last Name*Email Address*Phone*Pet Name*Pet Species*Preferred Appointment Date*Preferred Time of Day*Early MorningLate MorningEarly AfternoonLate AfternoonEarly EveningTo view our hours, click here: Hours & ContactReason for Appointment & Additional CommentsSubmit
