PETS Referral Center Online Check-In

PETS Referral Center

Emergency / Urgent Care Registration
Your Pets Name *
Primary Owner or Agent *

First Name Last Name
Co-Owner

First Name Last Name
Best Contact Number - {OwnerPrimary} *
Please enter the best number to reach you
Additional Contact Number - {coowner}
Enter number for co-owner or an alternate contact
May we send you text messages? *

Yes No
Best number for text messaging
Date of Birth for {OwnerPrimary} (required for dispensing controlled medications) *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
{OwnerPrimary} - Email Address: *
example@example.com
Any additional notes on how to best get in contact:
Have you been to PETS Referral Center with any pet? *

No Yes
Patient Information
Has {PetName} been to PETS Referral Center previously?

No Yes
Is {PetName} currently managed by one of our specialty services?
Photo of {PetName} (Optional)
jpg, jpeg, png or gif images only
Species: *

Cat Dog Rabbit
Breed:
Outside access and supervision:

My dog has free access to yard My dog has access to yard under supervision or is walked on leash My dog stays indoors and uses potty pad
Please indicate if {PetName} spends time

Indoor Only Indoor and Outdoor Mostly outdoor
How old is {PetName} *
Is the above age:

Known Estimated
Sex *
Color
When was {PetName} last vaccinated? *
Reason for your visit? *
Relevant History
Any Current Treatments/Medications *
Include dosing if known along with any supplements
Primary Veterinary Clinic *
We will automatically send records to the clinic you list here. Please include city.
Primary Veterinarian
Upload any relevant records, images or videos (Optional)

Browse Files
10MB max size Cancel of
COVID-19 Screening Questions

If you answer 'yes' to any of the questions below, our staff will take additional precautions to wear full personal protective equipment while working with your pet. In addition to the survey, please directly notify our staff if you answered yes to any of these questions. Thank you for helping keep our staff safe.
Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus? *

Yes No
Do you live in the same household with, or have you had close contact with someone who in the past 14 days has been in isolation for COVID-19 or had a test confirming they have the virus? *

Yes No
Have you felt ill in any way today or within the past 24 hours, which is new or not explained by another reason? *

Yes No
Submission Date

Month Day Year
Date
Submission Time

: Hour Minutes AM/PM Option
Should be Empty:

PETS Referral Center

Patient Information

COVID-19 Screening Questions