Consent to Treat - New Patient
Pet Owner Information
Thank you for helping us keep our contact information current!
Primary Pet Owner's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Are you....
New Client of Crossroads Animal Hospital
Established Client (registering a new pet)
Registering an additional pet (you already filled out a consent form)
Phone Type
Mobile
Home
Work
Other
Do you have a secondary phone number?
Please Select
Yes, I want to add another phone number
Nope, just the one phone number
Secondary Phone:
Please enter a valid phone number.
Secondary Phone Type:
Mobile
Home
Work
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Is there an additional owner authorized to make medical decisions?
Please Select
Yes, I want to add secondary owner
No
Example: Spouse
Additional Pet Owner's Name
First Name
Last Name
Additional Owner's Email
example@example.com
Additional Owner's Phone Number
Please enter a valid phone number.
Additional Owner's Phone Number Type
Mobile
Home
Work
Other
Do you have a Veterinarian Preference?
I strongly prefer Dr. Katie McCullough.
I prefer Dr. Katie, but either is ok.
Either Vet is fine.
I prefer Dr. Allie, but either is ok.
I strongly prefer Dr. Allie Brekke.
How did you hear about us?
Google
Facebook
Referred by Someone
Drive by
Other
Being referred by someone is the greatest compliment we can receive! Who referred you? (we'll send them a thank you gift)
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Pet Information
We can't wait to meet him or her!
Pet's Name
*
Pet's Date of Birth
*
-
Month
-
Day
Year
Make your best guess or choose Jan 1 of apx year if unknown.
Species
*
Dog
Cat
Other
Breed
*
Hint: Most cats are "domestic shorthair"
Color
*
Sex
*
Please Select
Female Spayed
Female Intact (not spayed)
Male Neutered
Male Intact (not netuered)
What does your pet eat? How much? How often?
*
Include brand, quantity, and frequency
What is your primary reason for requesting an appointment?
*
Example: Vaccines, Ear Infection, Limping, etc
Which best describes your cat?
Indoor only
Indoor/Outdoor
Mostly Indoor with limited outside time
Indoor only now, but used to be outdoor too
Is your dog on HEARTWORM prevention?
No
Yes, year round
Yes, only in warm months
Usually yes, but I have forgotten recently
What brand of Heartworm prevention?
Does your dog receive a TICK preventative?
No
Yes, year round
Yes, only in warm months
Usually yes, but I have forgotten recently
What brand of tick preventative?
Does your pet receive any medications?
*
Yes
No
Please list the medications, doses, and frequencies:
Does your pet receive any supplements or vitamins?
*
Yes
No
Please list the supplements your pet receives and how often.
What vet clinics has your pet been to in the last 3 years? (put n/a if necessary)
*
Has your pet ever had any of these?
*
Surgery other than spay/neuter/dental
Hospitalization or Major Illness
Vaccine Reaction
Adverse Reaction to Medication or Anesthesia
Seizures
Food Allergy/Sensitivity
Environmental Allergy
Skin or Ear or Infections
Anxiety
Fearful Behaviors
Aggression
Other medical or behavioral concerns
No Prior Medical Concerns
Please tell us more about the condition(s) you checked.
The more we know, the better we can help.
Is there anything we can do to make sure you and your pet have a good experience?
Psst! Don't be shy to tell us what has bothered you or your pet in the past. We want to avoid making the same mistakes.
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Policies and Consent to Treat
Last step, we promise!
24 Hour Exam Cancellation Policy
To ensure availability for all pets in need, please provide at least 24 hours' notice for exam cancellations or reschedules. Late cancellations may result in a fee equivalent to an exam.
7 Day Surgery Cancellation Policy
We reserve multiple hours and team members for each surgical procedure. Please provide 7 days' notice for cancellations or rescheduling to avoid a $100 late fee. For mobile specialists, 7 days' notice is also required to avoid a $200 fee.
Payment Method on File
All appointments require a credit card on file. Credit cards are stored securely as tokens in the medical records system, and team members cannot see the card numbers to protect the cardholder.
Prescription Refill Requests
Please provide 48 hours notice for refill requests. We'll notify you when your medication is ready for pickup. Requests can be made via phone, email, text, or our pet care app. Liquid prescriptions cannot be returned to stock; they must be dispensed upon request or covered by the owner.
Records Transcription by AI
I consent to have my interactions recorded within Crossroads Animal Hospital using artificial intelligence (AI) technology to accurately document medical records related to my pet's treatment and care.
Outside Pharmacy Requests
There's a $9.99 admin fee for prescription requests from outside pharmacies, waived if not available from our pharmacy. Written prescriptions can be picked up or emailed to owners at no cost with 24 hours notice.
Payment
Payment is due at the time of service. Payment plans are available through CareCredit and ScratchPay. Unpaid invoices left for over 14 days will incur a 5% late fee, recurring every 30 days. After 90 days, unpaid invoices will be sent to collections.
Audit Process
We strive for accurate invoicing, but mistakes may happen. If a service or product isn't charged during your visit, you may receive a follow-up invoice for it later.
Fear Free Policies
We prioritize your pet's comfort and safety. If our team believes further care may cause excessive fear or harm, we reserve the right to decline treatment in your pet's best interest.
Social Media Release
To reach as many pet parents as possible, we share educational content on social media. Signing this consent form allows us to use your pet’s photo on our social media platform.
Emergency Services
Crossroads Animal Hospital doesn't offer after-hours services. We recommend familiarizing yourself with nearby emergency facilities. Find more resources at www.crvet.org/ER.
Consent to Treat
I consent to the above policies by signing the document below. I confirm my ownership or agency over the named pet and affirm that I am eighteen years or older. I authorize the staff veterinarians at Crossroads Animal Hospital to examine, prescribe medication for, treat, hospitalize, sedate, anesthetize, and/or perform surgery on my pet after consultation with me. I acknowledge the inherent risks associated with medications, vaccinations, anesthesia, and surgery and agree to discuss any concerns with the attending veterinarian beforehand. In the event of unexpected life-saving emergency care, if unreachable, I authorize the hospital staff to provide treatment, and I agree to cover the associated costs. I understand that I will receive an estimate of fees for veterinary services and am encouraged to discuss all related fees before and during my pet's treatment.
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