URGENT CARE INTAKE FORM

Urgent Care Intake Form
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.
General Information
What is your pet's name?*

Tell us a bit about your pet*

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

What is your name?*

First NameLast Name
What is the best number that we can contact you at during your pets visit?*
Please enter a valid phone number.
What email address can we reach you with? Information about your pets condition may be sent via email. (if you do not have an email address, type NA@NA.COM*
example@example.com
Are you of legal age and the legal owner, or legal representative, of this pet?*

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.
Have you ever brought a pet to Mahalo in the past?*

YesNo
What is your home address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Is the pet you are bringing today one we have seen before?*

YesNo
Who is your regular veterinarian? We will send the record of your Urgent Care visit to your regular vet.*
Tell us about your pet and what is going on.
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.*

	Yes	No
Vomiting
Diarrhea
Constipation
Coughing
Excessive sneezing
Not drinking as much or at all
Drinking more then 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 then usual
Behavioural changes
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
Does your pet have known allergies and/or chronic conditions?

YesNoNot Sure
Please tell us about their allergies and/or chronic conditions
Has your pet had any adverse reactions to vaccinations, medications or anesthetics in the past?

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?
Our Urgent Care Appointment Procedures
- Urgent care is not for life threatening emergencies or 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 fees associated with an urgent care assessment and hospitalization, not including treatments, diagnostics, or medications, can be up to $250.00.
- This fee is the minimum required deposit for your urgent care visit and is due at the time your pet is admitted to the hospital.
- After this intake, your pet will be admitted to the hospital and examined by the Veterinarian.
- Your pet may be hospitalized for several hours.
- The Veterinarian will contact you by your prefered contact method to discuss any results and treatment options.
- 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 is required incase 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.

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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.

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Urgent Care Intake Form

General Information

Tell us about your pet and what is going on.

Our Urgent Care Appointment Procedures