URGENT CARE INTAKE FORM

After submitting this form, your pet will be added to our triage list. When we are able to see your pet we will call you to arrange a time. Please wait for our call. The following questionnaire must be completed prior to seeing your pet for their Urgent Care appointment so that the veterinarian has the most up to date information possible to help guide the diagnosis and treatment of your loved one. Thank You.

What is your pet's name?*

Tell us a bit about your pet*

Rows	Response
Age
Sex
Are they spayed or neutered?
Species (dog, cat, rabbit etc)
Breed
Colour

What is your name?*

First NameLast Name

What is the best number that we can contact you at during your pet's visit?*

Please enter a valid phone number.Format: (000) 000-0000.

What email address can we reach you with? Information about your pet's condition may be sent via email. (if you do not have an email address, type NA@NA.COM*

example@example.com

YesNo

If you are not the legal owner or representative, please provide the name and contact information for the legal owner so that we may contact them to confirm you have authority to make decisions on their behalf.

YesNo

What is your home address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?

Who is your regular veterinarian? We will send the record of your Urgent Care visit to your regular vet.*

What is the primary reason for your pet's appointment? Please include any specific symptoms you have noticed.*

How long has this been going on for? When did you first notice it?*

Please indicate if your pet is currently experiencing any of the following symptoms or if they have experienced them in the past.*

Rows	Yes	No
Vomiting
Diarrhea
Constipation
Coughing
Excessive sneezing
Not drinking as much or at all
Drinking more than usual
Urinating more frequently
Difficulty urinating
Urinary accidents (incontinency)
Loss of appetite
Eating more than usual - always hungry
Weight loss
Weight gain
Changes in breathing - increase or decrease
Bloated or tense abdomen
Lethargic, sleeping more than usual
Skin concerns (itchy, rashes, redness discharge, etc.)
Ear concerns (itchy, rashes, redness, etc.)
Eye concerns (discharge, blindness, etc.)
Lameness, limping, not weight bearing
Difficulty going up and down stairs
Behavioural Changes
Any other issues not listed (detail below)

If you checked "Yes" to any of the above, or if you pet has a previous history of any of these symptoms, please provide more details.

Please list any medications (including human over the counter medications), supplements, and/or topical treatments your pet has received in the past month and when they were last given

YesNoNot Sure

Please tell us about their allergies and/or chronic conditions

YesNoNot Sure

Please tell us more about the adverse reactions your pet has had

Is there anything else we should know about your pet or anything else you would like to discuss today?

Urgent care is not for overnight care. Some patients seen in urgent care may need to be transferred to an emergency or referral facility once they are assessed and stablized.
Please ensure that all pets are either on a leash or in a carrier.
One of our Veterinary Technicians will do your intake, asking you some details of your pets condition.
Please be prepared to spend 10-15 minutes with the Technicians for the intake. If your secondary contact person is dropping your pet off, they will need to be able to answer some questions. Having to reach you to answer intake questions may delay veterinary care for your pet.
During this intake an estimate may be presented to you. Our urgent care estimates are created based off of experience with similar cases.
The required deposit for your urgent care visit and is equal to the Urgent Care Exam fee and is due at the time of drop off.
After your intake, your pet may be admitted to the hospital to be assessed and treated. If your pet requires hospitalization the Veterinarian will contact you with findings from their assessment and to put together a treatment plan with you.
If we are arranging care for the following day(s), please make sure that you pet does not have anything to eat from midnight the night before, water is okay. Fasting may be required if certain blood tests or sedation are required. You are welcome to bring some of their food with them at the time of drop off.
If you have insurance coverage for your pet, please let us know at the time you check in.
If you require third party financing, please let us know when you check in. Third party financing is available on our website. Mahalo Veterinary Hospital does not offer payment plans.
When applying for third party financing request enough to cover the high end of your estimate. Any amount due beyond what is covered by third party financing or insurance is due at the time of picking up your pet.

By signing below, I agree that I have read and understood the protocol above.

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy, by another responsible party listed on my account, and/or by phone.

Urgent Care Intake Form

General Information

Tell us about your pet and what is going on.

Our Urgent Care Appointment Procedures