Emergency Room Admission Form

Is your pet a current patient under going care at our hospital?*

YesNo

Do you have an appointment with one of our specialist?*

YesNo

Specialty Admission Form

It looks like you were sent to the wrong location.

Please fill out the Specialty Admission Form instead.

Name*

First NameLast Name

Mobile Number*

Please enter a valid phone number.

Phone we can reach you for today*

Please enter a valid phone number.

Email*

example@example.com

Owner Date of Birth

Needed for RX and payment processing.

Owner Driver's License or ID#

Needed for RX and payment processing..

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you physically at the hospital now or are you on your way?*

How did you hear about our hospital?*

Pet Name*

Reason for Visit*

Species*

Breed*

ie: Lab, DSH etc.

Color*

Age: Age* *

Sex*

Spayed / Neutered? (fixed or altered)*

Primary Animal Hospital / Veterinarian*

Is your pet currently taking any medication?*

YesNo

Please describe current treatment or medication your pet is currently on.

Pre-Payment choice for your pet's treatment?*

Credit CardCashCare CreditScratch Pay

Medical/Surgical Treatment Authorization
I certify that I am 18 years of age or older and am the owner and/or responsible agent of the animal presented for diagnosis and/or treatment. I do hereby authorize TrueCare for pets, its doctors, staff, volunteers and/or agents to administer treatment as is considered therapeutically and/or diagnostically necessary on the basis of findings during the course of said evaluation. I further consent to the administration of such anesthetics and surgical procedures that are deemed necessary on the treatment of the emergent animal. I also certify that no guarantee or assurance has been made as to the results that may be obtained.

Signature*

Financial Responsibility

I assume financial responsibility for all charges incurred for this patient. I understand that any estimate rendered by the clinic is an attempt to predict as accurately as possible the costs of services performed. The exact amount of the fees shall depend upon various factors including, but not limited to, unforeseen circumstances that require additional services for the benefit of the animal. Any animal not picked up within the specified time frame may be transferred to the local Animal Shelter.

Should the animal require hospitalization, I agree to make a pre-treatment deposit in the amount of the estimated cost of treatment. I further understand that all fees are due and payable in full at the time of release of the animal.

Signature*

Arbitration Agremeent

All disputes arising out of this Agreement shall be resolved by binding arbitration under the rules of Judicial Arbitration as contained in California Civil Code of Procedure Section 1280 et. seq., which shall not include the right to formal discovery including depositions of parties and third party witnesses, subpoena duces tecum, form interrogatories, special interrogatories, rights of inspection and the Arbitrator shall not have the authority to order the same.

The forum for the arbitration shall be either, American Arbitration Association, Adjudicate West, Judicial Arbitration and Mediations Services of California (JAMS) or an arbitrator appointed by a court of law of property jurisdiction. The party first filing for arbitration shall select which of the above forums to use.

The award of the arbitrator shall be binding and either party may petition a court of competent jurisdiction to convert the award to an enforceable court judgment. A court of competent jurisdiction shall have the power to issue interim orders as the court deems appropriate to maintain the status quo pending the issuance of the award and or judgment. Each party shall pay their own Arbitration expenses, including legal fees, arbitrator's fees and arbitration administrative fees regardless of which side is the prevailing party and the arbitrator shall not have the authority to award such costs and or expenses to either side.

Signature*

Code of Client Conduct

I AGREE TO TREAT ALL STAFF WITH RESPECT. I UNDERSTAND THAT IF AT ANY TIME I EXHIBIT ANY OF THE FOLLOWING BEHAVIOR, I WILL IMMEDIATELY HAVE TO SEEK MEDICAL CARE FOR MY PET ELSEWHERE.

Verbal Threats
Menacing or derogatory gestures
Harrassing, offensive or intimidating statements
Racial or cultural slurs or other derogatory remarks

Code of Client Conduct

I AGREE TO TREAT ALL STAFF WITH RESPECT. I UNDERSTAND THAT IF AT ANY TIME I EXHIBIT ANY OF THE FOLLOWING BEHAVIOR, I WILL IMMEDIATELY HAVE TO SEEK MEDICAL CARE FOR MY PET ELSEWHERE.

Verbal Threats
Menacing or derogatory gestures
Harrassing, offensive or intimidating statements
Racial or cultural slurs or other derogatory remarks

Signature*

Photo/Video Release Authorization Form

By signing and printing my name below, I grant TrueCare for Pets, and their representatives and affiliates permission to take any and all information, photographs, and/or videos of me and/or my pet(s), and to copyright, use, post, and publish the above in both print and electronically.

I agree that TrueCare for Pets, their representatives and affiliates, may use such information, photographs, and videos of me and my pet(s) without my name and for any lawful purposes. These purposes include, but are not limited to the following: video, trade show booth, brochures, display advertisements, signage, Yellow Pages, newsletters, private invitations, social media platforms, websites, lectures, and marketing-related materials. This permission extends to all future usage, all future printings, and all future postings.

I understand that absolutely NO personal information, such as address, phone number, financial information, and material considered sensitive, will be released or made public. I also understand that there will be NO compensation from TrueCare for Pets, or their representatives and affiliates for the use of the photograph(s) and video(s) now and in the future. I will make NO monetary or other claims against TrueCare for Pets, or their representatives and affiliates for their use of the interview, information, photograph(s) and/or video(s).

Photo Release Signature