Central Carroll Animal Emergency Check In Sheet

Central Carroll Animal Emergency

1030 Baltimore Blvd Suite 180 Westminster, Maryland 21157
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Client and patient information to be entered below:
Have you been here before?
Owner Name

First NameLast Name
Owner Phone Number

Area CodePhone Number
Secondary Owner Name

First NameLast Name
Secondary Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Employer
Family Veterinary Clinic*
Color/Make/Model of Vehicle
AUTHORIZATION FOR MEDICAL AND/ OR SURGICAL TREATMENT AND FINANCIAL RESPONSIBILITY

I HEREBY AUTHORIZE Central Carroll Animal Emergency, LLC to examine and treat the animal described below medically and/ or surgically. I understand there is no guarantee of successful treatment. I also consent to the administration of such anesthetics as are necessary and surgical procedures of an emergency nature. I assume complete financial responsibility for any and all charges incurred to patient for such exam and treatment. I further understand that emergency patients must be picked up from this facility by 12:00 am, on Saturdays and Sundays, 1:00am on weekdays. Through the week we do not offer 24 HR care. I hereby agree to pay at the time services are rendered. I understand that Central Carroll Animal Emergency, LLC does not bill for any services or items. I have read and fully understand this authorization for medical and/ or surgical treatment.

I UNDERSTAND THERE IS A $95 EXAM FEE.
We accept the following (with valid Drivers License):

Cash/Visa/MasterCard/Discover/American Express/Checks

*There will be a $35 return check fee for all returned checks*
We CANNOT accept Home Equity Line of Credit Checks or Business Checks.

If money is an issue please ask us about CARE CREDIT or SCRATCHPAY
Signature
Please enter your full name to agree to the above terms.
Date
Patient Name
Species
Breed
Gender
Spayed/Neutered?
Age
Color
Up to date on vaccines?
Current Medications
Brief Description of Symptoms
Please intial here if we have your permission to to take photos of your pet and post to our social media account
If you submit a form prior to our hours of operation, please call when you get to the parking lot!
Should be Empty:

Central Carroll Animal Emergency

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If you submit a form prior to our hours of operation, please call when you get to the parking lot!