EMergency Care check-in form

GREEN ACRES VETERINARY CENTER

2060 Niagara Falls Boulevard Tonawanda, NY 14150

greenacres@buffaloveterinarygroup.com

greenacresveterinarycenter.com

(716)-694-0122
EMergency Care check-in form
Client Information:
Full Name

First NameLast Name
Spouse's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Preferred Contact Method:
Have you been to this emergency facility before?
Patient Information:
Pet's Name:
Name:
Breed:
Color:
Age/Date of Birth:
Sex:
Is your pet spayed/neutered?
Has your pet been to another veterinarian?
Name of Veterinarian or Hospital:
Is your pet up-to-date on his/her rabies vaccine?
How did you hear about us?
Please Specify
What medications is your pet receiving, if any?
Payment Policy

We accept cash, Mastercard/VISA/Discover/American Express and CareCredit. Payment is expected when services are rendered. We will gladly prepare you a written estimate of services prior to the treatment of your pet if you desire. I realize and understand that I am financially responsible for the care and treatment of my pet(s). I further agree that in the case of non-payment, a finance charge or interest fee and collection fees will apply.
Emergency Authorization to Stabilize Pet:

Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs, or other heroic interventions, I request that the doctor(s) at Green Acres Veterinary Center pursue such medical care as they deem necessary. Having requested such emergency procedures, I agree to be held responsible for the resuscitation fee. Regardless of my pet's survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me. I understand that despite the best efforts of the doctors and staff at this facility, even the most successful CPR that stores my pet's life may not allow my pet to regain his normal mental and physical health.
In an attempt to save your pet's life, we need your IMMEDIATE authorization to stabilize him/her as well as for financial responsibility.
- I authorize Green Acres Veterinary Center to attempt to stabilize my pet immediately.
- I understand and agree to pay a minimum of $750.00.
- I understand the continued treatment and/or repair will cost more.
Signature
Should be Empty:

EMergency Care check-in form

Payment Policy