EMERGENCY PATIENT CHECK-IN

EMERGENCY PATIENT CHECK-IN

Registration Information
Practice Policy

*Required to move forward.
Please CALL us upon your arrival at MVER.

603-279-1117

Welcome to MVER. It is unfortunate that you and your pet have to be here today, but we want to help you and your pet.

Please be aware that we are the only after-hours veterinary facility in the Lakes Region of New Hampshire.

Like most veterinary practices across the country, MVER is caring for a significantly greater number of patients since 2020. At times our facility does not always offer enough space to invite every single client and patient into the building for the duration of your visit. Our exam rooms are reserved initially for clients and patients with the most serious, potentially life-threatening conditions, and for those families making end-of-life decisions. Then, if space allows, those clients and patients with less urgent conditions may be invited in. Stable patients may remain entirely curbside.

Thank you for waiting and respecting the families of patients, and the patients themselves, whose lives are on the line, where seconds can count.

ZERO TOLERANCE POLICY

We understand that coming to the emergency room can be inconvenient and stressful, however your patience is not only appreciated, but also required and expected.

There is never a reason to verbally assault our dedicated staff in person, on the phone, or on social media. Please choose to be above that.

Anyone who chooses to behave poorly or become belligerent with any staff member will be asked to leave immediately. Future services may be denied.

This is a place for calm and healing, we ask that you respect that and act accordingly.

Your signature below acknowledges that all services, except in extreme life-threatening situations, will not be rendered without an agreement to the above Practice Policy and that care may be terminated in the event of aggressive behavior or verbal or physical abuse or threats towards any staff member at any time.
Signature*
Date*

MonthDayYear
Date
CLIENT / OWNER INFORMATION
Client Name (Person)*

First NameLast Name
Are you the legal owner of this pet and at least 18 yrs of age? *
Yes / No
Have you arrived at MVER yet? If not, what is your estimated time of arrival?*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number *

Area CodePhone Number
BEST Phone Number to be reached at TODAY: *

Area CodePhone Number
Cell Phone Number *

Area CodePhone Number
Email*
example@example.com
Spouse/Other Name

First NameLast Name
Family Veterinarian Information

Please answer the following questions so that we may provide a complete medical record to your family veterinarian upon your pet's discharge.
What veterinary hospital does your pet visit for routine care?*
PATIENT / PET INFORMATION
Pet's Name*
Species *
Cat / dog / other
Breed*
(cats - Domestic Shorthair, etc)
Birthdate or approx age*
Gender*
Male / Female
Spayed/Neutered*
Yes / No
Pets' Approximate Weight Today:*
Color*
What is the reason for your visit today?*
When did the problem begin?*
NoYes, please list below
Medications:
Does this pet have any significant medical history (chronic issues, past surgeries or hospitalizations, etc)?*
Has this animal bitten anyone in the last 10 days? If yes, who was bitten and what were the circumstances?*
Is this animal up to date on vaccinations, in particular, a Rabies Virus vaccination?*
Tell us about this pet's diet/eating habits - what type of food, how often, when did s/he last eat?*
Does this animal live mostly indoors, mostly outdoors, or both?*
Please list any other pets in the household that this pet is exposed to:*
Has this animal ever had any seizure activity? If yes, please explain:*
Yes, please!No, thank you
Has this animal ever had a need for pre-medication or muzzles due to aggressive behavior at a veterinary hospital? Please explain:*
Does this animal have any history of allergies to medications or reactions to anesthesia of which you are aware?*
YesNo
Is there anything else we should know regarding your pet?*
Signature of Recognition:

I, the undersigned, give permission for the doctors and staff of the Meredith Place Veterinary Emergency Hospital (MVER) to evaluate the above-named animal (Patient). I assume financial responsibility for all charges incurred and agree to pay all such charges at the time services are rendered. I also understand that checks or third-party credit cards cannot be accepted. I am responsible for interest and collection fees on any unpaid balance. I am 18 years of age or older.
Date*

MonthDayYear
Date
Signature*
CALL US UPON ARRIVAL
603-279-1117
Should be Empty:

EMERGENCY PATIENT CHECK-IN

Practice Policy

CLIENT / OWNER INFORMATION

Family Veterinarian Information

PATIENT / PET INFORMATION

CALL US UPON ARRIVAL603-279-1117

CALL US UPON ARRIVAL
603-279-1117