Patient Registration Form

Customer Details:
Was your pet assessed as critical and taken to the treatment area for stabilization?

YesNo
If your pet was taken directly to the treatment area, our staff may be requesting immediate authroization for treatment. They will keep you informed of cost throughout the process. The initial cost of treatment for emergent needs can be $700-$800. Please inform the staff if there are financial constraints regarding care as quickly as possible. AERC will do our best to provide care within your financial means. Total cost of care will be greater than $700 for critical patients.
Full Name*

First Name Last Name
Phone Number - Cellular*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number - Secondary
Phone Number - Work
Primary Veterinary Clinic*
If Banfield please specify which location
Patient Name*
CPR Directive*

CPRDo NOT Resuscitate
Age*
Species*

CanineFelineOther
Sex*

MaleFemale
Altered Status*

IntactSpayed/NeuteredUnsure
Breed*
Color*
Does your pet have any previously diagnosed conditions*

YesNo
Please select which previously diagnosed medical condition(s)*

Anemia or autoimmune diseaseAsthmaPneumoniaCancerDiabetesSeizuresLiver diseaseAddisonsCushingsHeart DiseaseKidney DiseaseNeurologic DiseaseGlaucomaOther
The following section(s) lists the options presenting problem(s). These options are separated into emergent or urgent complaints. Should you choose an option from the emergent section, the remaining urgent complaints will be removed from the form. Emergent complaints will receive a techinician assessment as quickly as possible because these complaints can be related to life-threatening situations.
Emergent

Changes in gum colorTrouble BreathingCoughingPanting (Feline/Cat)Vomiting with bloodRetching with no productionVomiting more than 8 times (in the last 24-48 hours)Vomiting 4-7 time (in the last 24-48 hours)Diarrhea with bloodDark or Black diarrheaDiarrhea more than 8 times (in the last 24-48 hours)Diarrhea 4-7 time (in the last 24-48 hours)Vomiting & DiarrheaBloated (distended abdomen)UnresponsiveActively seizingMultiple seizures (in the last 24-48 hours)Seizure (feline/Cat)Loss of balanceAltered MentationDragging a limbUnable to walkRapid eye movements (Feline/Cat)Disoriented (Feline/Cat)Head Tilt (Feline/Cat)Major Laceration (cut) / WoundToxin Ingestion (i.e. ate rat poison)Foreign object ingestion (i.e. swallowed a toy)Limping - won't place weight on the limbBroken/fractured boneBlood in urineTrouble urinatingUnable to use hind legsTrouble giving birthFeverBruisingFaintingVaginal dischargeUnable to urinateMajor injury to eye(s)Swollen FacePenetrating wound to the eyeEnlarged eyeHivesMass / Growth bleedingLeaking urine
Urgent

PantingSneezingVomiting 1-3 times (in the last 24-48 hours)Diarrhea 1-3 times (in the last 24-48 hours)Decreased appetiteConstipationSingle seizureFirst time seizureRapid eye movements (Canine/Dog)Head tiltDisorientedMinor Laceration (cut)/ WoundLimping - placing weight on the limbBroken toenailDrinking / urinating more frequentlyUrinating outside of the litter boxMinor injury to eye(s)Itchy ear(s) with swellingItchy ear(s)Discharge from ear(s) or eye(s)Bloody noseNasal dischargeRashHair lossMass / GrowthItchy skinOther
The option(s) you've selected for the reason(s) for your visit places your pet in our stable triage line. Please provide our staff with patience and understanding while they're serving patient's and their clients in pontentially life- threatening situations.

If you feel this form has inaccurately assessed the criticality of your pet, please speak with the triage team at our front desk.

Animal ER Care happily serves the Colorado Springs community for all their emergent and urgent needs. Stable patients will experience extended wait times during a high volume of critical patients within our facility.
The option(s) you've selected may indicate a need for immediate assessment by our triage staff. Please bring you pet into our waiting room to inform the front desk.
The option(s) you've selected may require us to contact pet poision control, if you haven't already contacted them please call one of the numbers below. You'll be provided a case number, please write down this number to give to our veterinary staff. These services are associated with an additional fee you'll pay directly to that hot line. There is an online chat/text option with the ASPCA poison control for a reduced cost.

Pet Poison Helpline - (800)213-6680

ASPCA Poison Control - (888)426-4435

Our veterinarians have general information related to raisins/grapes, ibuprofen/carprfen, white/milk chocolate, and THC/marjiuana. If your pet ingested one of these items please speak with our triage team prior to contacting poison control.
Poison Control Contacted

ASPCA Poison ControlPet Poison Hotline
Poison Control Case Number
Please list your pet's current medications (prescribed and/or over the counter) and last time they received them. Enter NONE if your pet isn't currently taking any medication.
Vaccination Status*

Up To DateDue For BoostersNever Vaccinated
How does your pet do when visiting the vet's office?

Happy/FineScared/AnxiousProtective/May Bite
How did you hear about us?

Primary VeterinarianWebFriendHave been here before
Payment Policy and Authorization
- I understand that ALL charges are due at the time of service(s).
- I'm aware the initial doctor examination fee is $175.00.
- Animal ER Care, LLC makes every effort to ensure that all charges are entered at the time of discharge. However, if missed items are found, I understand that I am liable for these charges and will pay said charges within 30 days of the billing date.
- I assume all responsibility for charges incurred in the care of this pet and will ask any questions regarding this payment policy before services rendered. I understand that there will be a $25.00 returned check fee assessed to my account on all returned checks.
- I agree, that in the event that my account is turned over to a collection agency or attorney due to non-payment, that I will pay an additional $30.00 as reasonable collection fees plus any collection costs and attorney's fees incurred in connection with the collection of my account.
- I authorize Animal ER Care, LLC to examine, prescribe for, and treat the above pet. I consent to the release of medical information to and from my family veterinarian(s).
- We occasionally take photos and videos and/or blog about our patients. To opt your pet out of this option please complete the last question on this form.
By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully.
Date*

MonthDay Year
Hour Minutes AM/PM Option
I provide Animal ER Care with permission to use pictures or videos of my pet.*

YesNo
Signature*

Clear
Date*

MonthDay Year
Date
Hour Minutes AM/PM Option
Should be Empty:

Customer Details: