Emergency Registration Form SCVSEC

Owner Name

First NameLast Name

Co-Owner/Agent Name (If applicable)

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / 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

Email

example@example.com

Are you....

Patient Name

Date of Birth or approximate age

Species

Pet breed

Pet coat color

Pet gender/spay and neuter status

Primary care veterinary practice

Primary care veterinarian

Please describe your reason for visiting

Our Emergency Department consultation fee is $198.90 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.

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.

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.

Emergency Registration Form

Client Information

Patient Information