SKVH New Client Consent / Existing Client/ Intake / Symptom Form

Who we are.
We are a locally owned and operated clinic. Our veterinarians do not work on commssion. Please rest assured that we have your pet's best interest in mind.

In public interest.
We see a lot of animals affected by issues / conditions / diseases which require intensive care, long term medical therapy or a surgery. Please get your pet insured to have a peace of mind. We do not prefer any one insurance company but the popular ones are Trupanion, Pets Plus Us, Petsecure, OVMA Pet Health Insurance and Petplan.

Can we contact you?

Stittsville Kanata Veterinary Hospital uses email, text, and our own hospital app for communications regarding our patient's reminders for health care needs. By clicking 'Next' you provide us permission to contact you via email, text, and/or our app regarding these reminders? You can also unsubscribe at a later date.

Reminders for appointments / tests / surgeries etc
Stittsville Kanata Veterinary Hospital may not provide reminders for appointments or due services by mail. If you choose not to be contacted by email, text and/or our hospital app, we cannot guarantee timely reminders regarding your pet(s) health. If choosing not to provide permission to contact you digitally, please initial below indicating that you understand the above and release Stittsville Kanata Veterinary Hospital from any liability surrounding notification (timely or otherwise) regarding your pet(s) health care needs.

Payment
We accept Amex, Visa, Mastercard, and e-Transfer. We also accept cash. Full payment is due at the time of service. This includes any charges/fees agreed to by authorized proxy. Our team is happy to provide a written treatment plan prior to services being rendered if requested by you.

Cancellation & Rescheduling
I will read and follow the updated cancellation / rescheduling policy on www.skvh.ca if needed and will abide by the mentioned costs and fees.

The problem might or might not be resolved today
I understand that I might not get a final diagnoses for my pet. I will get the proper care according to the standard of care according to the current clinical signs.

I agree that the my file will be terminated immediately and may be forwarded to my next veterinarian's office (including the communication and my behaviour) if I (or someone on my behalf) exhibit(s) threatening practices, or if I indulge in actual or perceived calumny especially defamatory reviews, ratings or statements. I also assume any and all liability in case I, intentionally or unintentionally, cause any provable or perceived damage to the hospital's reputation.

General Consent
I understand that as in human medicine, there cannot be any guarantee to an animal’s condition or outcome of any procedure, and that every procedure requiring anesthetics carries a risk from a minimal one to one that of death. In case of unintended outcome, I am still liable for paying for all the services already provided to my pet. Unpaid accounts would be sent off to collection agencies. We are working with living beings. Please understand that we can provide you with competent advice but even when all procedures are correctly followed, your pet's condition can get worse or other conditions might appear. The diagnostics, treatments or surgeries done on your pet might make your pet's condition worse. We do everything we can to make animals feel better again. For this, we employ a competent staff, use high end technology, and have highly experienced veterinarians willing to go the extra mile for your pet. I understand that I always have an option to ask for a referral to a specialist or to an emergency clinic if I feel that my pet’s condition requires critical care. I authorize the performance of required procedures and the use of associated anesthetics and other labeled / off label / compounded medications for the treatment of my pet. If I need any more information about any of these, I am responsible for asking these questions. We can only provide information if you request it. I understand that due to extreme shortage of veterinarians, some of the procedures, diagnostics or treatments may be performed by veterinarians holding restricted licenses under direct supervision. I understand that unforeseen conditions may be revealed during any procedures which, in the opinion of the attending veterinarian, may require more extensive/different treatments or may lead to minimal side effects to that leading to the death of the patient. I understand that reasonable efforts will be made to contact me to explain all procedures and treatments and obtain my verbal or written instructions regarding them. However, if the efforts are unsuccessful, I authorize the performance of any procedures or treatments which might be life saving in the professional opinion of the attending veterinarian. I have agreed to guarantee the payment of the sum of all clinic fees. These fees will be paid at the time that the animal is discharged and hereby acknowledge my indebtedness for those amounts. It is understood that, if I do not pay this account as agreed, past due accounts are subject to costs of collection, including attorney’s fees. In the event that the pet referred to above is not claimed by the person giving this consent within ten (10) days of any services provided by the Stittsville Kanata Veterinary Hospital, the pet shall be deemed to have been abandoned, and the Stittsville Kanata Veterinary Hospital shall be entitled to transfer the pet to humane society and I would not have any right over my pet. By signing here and submitting the form you are giving the Stittsville Kanata Veterinary Hospital your consent to send vaccine reminders, newsletters and other veterinary updates by email /text and other forms of communication. You may change this preference at any time by calling us. I have read and understood this authorization.

Professional Environment
We aim to maintain a professional working environment in the clinic. Any harassment or violence cases would be reported to the authorities and the client / non-client would be banned from entering the clinic premises. Immediate termination of file if client is rude or disrespectful. Please he aware that this file may be forwarded to your next vet.

Medications non - refundable
I understand that SKVH cannot provide any guarantees regarding the recommendations, treatment or medications. The medications are non-returnable as mandated by Health Canada. There are no refunds provided for anything for any reason. Please choose responsibly.

Disclaimer
The recommendations about tentative diagnosis, diagnostics and treatment would be given for the clinical signs that are described here. If clinical signs of any condition are not present currently and if they show up later on, we will not be responsible for it. The pet owner will be responsible for keeping us up to date on changing clinical picture to get proper advice.

Strict Cancellation / Rescheduling Policy
Since we have limited appointment / surgery slots, we discourage wastage of the same by enforcing a strict policy. Please read carefully at www.skvh.ca under 'Cancellation policy'. This ensures that pets who actually need veterinary care are able to access it. By clicking next, you agree to this policy.

Have you texted us to secure the 'Tentative Date & Time" for your appointment (not confirmed but tentative)

Yes No

When you texted us, what 'Tentative Date & Time" for your appointment did we give you. *

Consult fee only for appointment within 24 hours (if available) = $175 + HST. For vaccines after 24 hours, the cost is $95 + cost of the vaccines. For any medical appointment not needed within 24 hours, the consult fee is $125 + HST.

Hour Minutes AM/PM Option

Owner's Name *

First Name Last Name

Will the owner be dropping off and picking up the pet ? *

Yes No

Why would the owner not be bringing the pet in instead of the pet owner? And do you have owner's consent for bringing their pet in? *

Have you pet been seen by our vets before FOR A CONSULTATION. Click no if you are not sure. *

Yes No

Pet Owner's Address *

Cell Number for texting & calling *

Please enter a valid phone number.

Email address of primary owner *

example@example.com

Occupation of primary owner *

Pet co-owner / Emergency Contact (leave empty if no secondary owner)

First Name Last Name

Phone Number of Pet co-owner / Emergency Contact

(leave empty if no secondary owner)

Email address of secondary owner / Emergency Contact

(leave empty if no secondary owner)

Occupation of Pet co-owner / Emergency Contact

(leave empty if no secondary owner)

Pet Insurance Company (if insured)

RECOMMENDATION: Get ANY pet insurance. We do not recommend a particular one due to ethical reasons.

How many pets are you registering today ? *

One Multiple

Multiple Pet Registration *

	Name	Date of Birth	Species	Breed	Color	Sex	What needs to be done in the appointment ?
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5
Pet 6
Pet 7
Pet 8

Pet's Name *

First Name Last Name

Pet's Date of Birth *

Date

Species *

Breed *

Color *

Sex *

Microchipped *

Any changes to your contact information ? If nothing has changed, please write 'None'. *

If your pet has been seen at a DIFFERENT CLINIC recently for this or a similar issue, write clinic name and location so we can request records be sent prior to your appointment. If not, write 'None' *

Is your pet on any MEDICATIONS including heartworm / tick / flea / supplements etc ? Which ones? What dose and how often ? Do you need any refills ? Write 'none' if your pet is not on any medications. *

FOOD / TREATS / DIET ? Which ones? *

VEHICLE Make, Model & Color *

Reason for visit. We cannot combine vaccines with medical appointments. *

Vaccine / Wellness / Pre-surgery check (No medical issues are covered, only a basic exam to verify your pet is healthy for vaccines. Please select 'Medical Issues' if you'd like the vet to go over any issues / concerns. UNFORTUNATELY, WE CANNOT ADD MEDICAL ISSUES IN THIS EXAM. Please select carefully. Medical Issue (Vaccines can be done only after Veterinarian's medical evaluation and if the veterinarian believes it is safe to do so . Please select carefully. Surgery Prepayment

Do you require any of these ?

Health Certificate (Local) Health Certificalte (International) Rabies Certificate for travel / boarding Heartworm / Lyme / Ehrlichia / Anaplasma Test (4Dx in Dogs, recommended every spring) Feline Infectious Virus / Feline Leukemia Virus Test (For new cats, barn cats & cats sick for unknown reason) None

Which recommended parasite prevention medications are you interested in ? This is part of wellness routine ?- (select all that apply) *

Intestinal Parasites (Dogs should get this all year round or during spring, summer and fall) - (Indoor cats should get this every 3 months at least and outdoor cats should get it every month as preventatives) Heartworm (Recommended from May to November) Ticks (Recommended anytime temperature is above 0 C for a week or above, usually dine from March to December) Mites (puppies, old pets, immunocompromised pets or in case of infestation) Do whatever's best at the time None Fleas (when you bring new pets home, or in case of infestation)

Vaccines Up to date ? *

Yes No Unsure

BRIEFLY NAME ALL PAST RELATED MEDICAL CONDITIONS *

Select all applicable clinical signs that you are concerned about. *

Coughing - started how many days ago? *

Coughing - how many times? *

Coughing - when does it happen? *

Anytime When sleeping During the day When excited When exercising During certain season When pulling on leash On walks Other

Coughing - correlation *

Went to daycare / boarding recently, in contact with other pets Vaccinated with Kennel Cough Not vaccinated with Kennel Cough Ate something that he / she shouldn't have

Coughing - what is brought up? *

Nothing Phlegm Foam Mucus Vomit

Sneezing - started how many days ago? *

Sneezing - what is brought up? *

Nothing Mucus discharge Green discharge Blood discharge Grey Discharge Clear discharge

Sneezing - which side? *

Left Right Both

Sneezing - how many times a day *

Occasionally Frequently Rarely Daily Hourly Multiple times an hour

Vomiting - started how many days ago? *

Vomiting - how many times a day *

Vomiting - What is brought up ? *

Nothing Food Bile Foam Greenish stuff Blood Other Grass that was eaten

Vomiting - happens how much time after eating. Write 'NA' if no correlation. *

Vomiting - My pet may have gotten into things like toys, foam, tamp[ons, clothers, plastic, string, toys etc *

Yes No Maybe

Diarrhea - started how many days ago? *

Diarrhea - how many times a day *

Diarrhea - What is in the diarrhea ? *

Diarrhea - is your pet currently on any parasite prevention ? *

Yes No Not sure

Diarrhea - is your pet straining to defecate ? *

Yes No Not sure

Diarrhea - is your pet asking to go out more frequently ? *

Yes No Not sure

Constipation - started how many days ago? *

Constipation - is your pet straining to defecate ? *

Yes No Not sure

Urination - started how many days ago? *

Urination - select all that apply. *

Appetite Change - started how many days ago? *

Appetite *

Increased Decreased Not eating Eating anything Eating only junk food / treats

Energy - started how many days ago? *

Energy *

Increased Decreased

Dental Issues - started how many days ago? *

Dental Issues - what do you see. *

type your dental concerns here.

Water Intake Change - started how many days ago? *

Water Intake *

Increased Decreased

Behavior Change - started how many days ago? *

Behavior - please explain what changes you see. *

Weight Change - started how many days ago? *

Weight Change *

Increased Decreased

Skin Issues - started how many days ago? *

Skin Issues - what do you see ? *

Limping / Stiffness - started how many days ago? *

Limping / Stiffness - which leg, what's the issue ? *

Anal Gland Issues - started how many days ago? *

Anal gland Issues - which side, what's the issue ? *

Lumps / Masses - started how many days ago? *

Details about lumps

	Lump 1	Lump 2	Lump 3	Lump 4	Lump 5
Where is this lump ?
When did you first see it ?
Growing Fast ?
Any discharge ?
Other notes ?

Breathing Issues - started how many days ago? *

Breathing Issues - what is going on, please describe. *

Eye Issues - started how many days ago? *

Eye Issues *

Ear Issues - started how many days ago? *

Ear Issues *

Nose Issues - started how many days ago? *

Nose Issues *

Paw Issues - started how many days ago? *

Paws - please describe *

Nail Issues - started how many days ago? *

Nail - please describe *

Stretching body & Neck - started how many days ago? *

Seizures - started how many days ago? *

Seizures - describe the episodes

Parasites seen - started how many days ago? *

Please describe anything that was not an option above. Or add more details about your concerns. *

Type 'NA' if not applicable.

Signature *

Clear

Select appropriately to avoid any delays to your appointments. *

Surgery Prepayment Your slot will be confirmed after we text you back once this form is completed.

$ 95.00 CAD Quantity

$175 Appointment within 24 hours of receipt of this form + us texting to confirm your appointment / Any medical consult done on a Saturday / Any recheck done on a Saturday. [24 HOUR APPOINTMENTS] The forms are only received during working hours. Please check our timings. eg: If you submit this form on a Saturday evening when we are closed, this form would be received on Tuesday morning when we open. The appointment would then be given within 24 hours of Tuesday morning as per availability. Text us at 343-463-8787 for more info.

$ 50.00 CAD Quantity

$125 Appointment (Medical) after 24 hours of you completing this form out + us texting you back to confirm the appointment according to availability. Please text us after you fill this form out as to which date you'd like the appointment to be at. The appointment would be at least 24 hours after we receive this form (only during business hours). eg: if you fill this out on a Saturday evening, we will receive this on Tuesday morning, and then your appointment would be some time on Wednesday according to availability.

$ 50.00 CAD Quantity

$95 Appointment (Wellness / Vaccines) after 24 hours as per availability. NO MEDICAL ISSUES COVERED IN THIS BASIC EXAM. This exam only verifies that your pet is healthy enough to get vaccines. If you'd like the veterinarian to check any health issues, please select the medical consult.

$ 50.00 CAD Quantity

$60 Pre Surgery Check up (only for spays and neuters when pet hasn't been seen before, not a vaccine consult)

$ 50.00 CAD Quantity

$98 4Dx test Lyme / Heartworm / Ehrlichia / Anaplasma blood test for dogs. Usually takes 15 minutes.

$ 10.00 CAD Quantity

Subtotal

$ 0.00 CAD

Tax

$ 0.00 CAD

Total

$ 0.00 CAD

Credit Card

Sorry, you cannot fill this form out unless you receive a 'Tentative Date & Time" for your appointment. Please text us at 343-463-8787 asap. You should receive a quick response during our working hours.

SKVH Combination Form

Credit Card