Emergency Registration Form
Client Information
Owner Name
*
First Name
Last Name
Co-Owner/Agent Name (If applicable)
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Co-Owner/Agent Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Option
*
Cell
Co-Owner Cell
Home Phone
Work Phone
Email
*
example@example.com
Are you....
An employee of a veterinarian office
An employee of Thrive Pet Healthcare Partner Hospitals
Patient Information
Patient Name
*
Date of Birth or approximate age
*
Species
*
Dog
Cat
Pet breed
*
Pet coat color
*
Pet gender/spay and neuter status
*
Male
Neutered male
Female
Spayed female
Primary care veterinary practice
*
Primary care veterinarian
Please describe your reason for visiting
Our Emergency Department consultation fee is $185.44 and includes a physical exam. I authorize the veterinarian to perform this exam. I assume all financial responsibility and understand full payment is due at discharge. I understand that there may be additional fees assessed for treatment and diagnostic services beyond the initial physical exam. A 75% deposit based on the high end of the provided estimate will be required. Any remaining balance is due when the patient leaves our care. All fees are non-refundable. I understand that final charges may vary from the initial estimate if conditions are other than those anticipated. I understand there are inherent risks and complications associated with sedation, anesthesia, treatment procedures, surgical care, and administration of medications. I understand that these risks and that these complications are managed to the best of our ability but that no guarantee or warranty is made regarding ultimate result. I understand that all reasonable precautions will be taken to ensure the safety of my pet and that I am responsible for any related fees. I understand that pursuant to SC Code of Laws Section 47-3-110, a patient not picked up at discharge or left at the hospital without an agreed upon course of action, will be considered an abandoned animal.
*
I agree to the above treatment consent
PHOTO RELEASE: I grant SCVSEC permission to use photographs of my pet with/without my name and for lawful purposes that include publicity, illustration, advertising, educational purposes, and web content to copyright, use and publish in print or electronically without compensation.
*
I agree to these terms
CODE STATUS: In the event your patient goes into Cardiac/Respiratory arrest during treatment, the attending staff will need a CPR/DNR designation. A CPR designation may increase cost by $750-$900.
*
I approve CPR for my pet
I do not wish CPR for my pet (DNR)
Submit
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