Patient Registration Form

Customer Details:
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 NameLast Name
NoYes
Phone Number - Cellular*
Format: (000) 000-0000.
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - Secondary
Format: (000) 000-0000.
Phone Number - Work
Format: (000) 000-0000.
Primary Veterinary Clinic*
If Banfield please specify which location
Patient Name*
CPRDo NOT Resuscitate
Age*
CanineFelineOther
MaleFemale
IntactSpayed/NeuteredUnsure
Breed*
Color*
YesNo
Anemia or autoimmune diseaseAsthmaPneumoniaCancerDiabetesSeizuresLiver diseaseAddisonsCushingsHeart DiseaseKidney DiseaseNeurologic DiseaseGlaucomaOther
Primary Reason for your visit
Pet Poison Helpline - (800)213-6680

ASPCA Poison Control - (888)426-4435

Our veterinarians have general information related to raisins/grapes, ibuprofen/carprofen, 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 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.
Up To DateDue For BoostersNever Vaccinated
Happy/FineScared/AnxiousProtective/May Bite
Primary VeterinarianWebFriendHave been here before
AI Software Consent and Release

Our veterinary services utilize AI software, which records your conversations with our team to transcribe the information into your pet's clinical record. This includes:Appointment Recording: Your conversation with our staff may be recorded to facilitate accurate medical records. Usage Rights: You grant us permission to share these recordings and any other materials you choose to provide for the purpose of improved clinical documentation. Age Confirmation & Understanding: You affirm that you are at least eighteen years old, and that you understand and accept the terms in this agreement. We are committed to providing the best care for your pet in a manner comfortable for both of you. Please let us know if you are not authorizing Animal ER Care to use AI software.
Signature

Clear
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 $180.00.
- 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*

MonthDayYear
Hour MinutesAM/PM Option
YesNo
Signature*

Clear
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Customer Details:

AI Software Consent and Release