ER Check-In Form

ER Check-In
Full Name*
Email*
Phone*
Address*

Address

Address Line 2

CityState

Zip Code
Driver's License Number Or Other ID Information*
New or Existing Patient*

NewExisting
Pet's Name*
Pet's Age / Birth Date *
Sex*

MaleFemaleUnknown
Is your pet spayed/neutered*

YesNo
Breed*
Color/Markings*
Is special handling required*

YesNo
Pet Insurance*

YesNo
Please list your insurance provider's company name and policy number *
Reason For Visit *
When did you first notice these signs?*
Any allergies/sensitivities?*
Any history of seizures?*

YesNo
Current medications/supplements/treatments (please include dosages)*
Relevant history*
CPR Wishes*

Approved - CPRDeclined - DNR
Pet's primary veterinary hospital & veterinarian name*
Anything else we should know?*
Referral Client Policy:

VET PR’s Emergency & Specialty Care services are designed to function as an extension of your primary veterinarian's facility. We provide local and referring veterinarians with after-hours emergency services, specialized medical procedures, and critical care hospitalization for their clients’ pets. We value the partnership we have with your veterinarian, and for that reason, they will provide follow-up services and continued care once our emergency or specialized services are no longer necessary. We will immediately notify your veterinarian that your pet visited our hospital and provide them with treatment and follow-up information so they can continue your pet’s care once you leave our hospital. Thank you for entrusting VETS PR with your pet’s emergency and specialty care.
Firma*

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Financial Policy:

Following a doctor’s examination, we will provide you with an estimate of fees for your pet’s medical care. You will have the opportunity to approve or decline all recommended procedures or medications. Your estimate will be adjusted to reflect only the services that you wish to pursue. Upon approval of the estimate, a deposit is required to begin diagnostics and treatment on your pet. THE BALANCE IS DUE AT DISCHARGE. If you cannot meet this requirement, we have staff members who can assist you in applying for a payment plan. If you have any concerns, please feel free to consult our reception staff.
Firma*

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