Intake Form - Emergency Animal Hospital of Ellicott City

I agree and understand that by typing my name below, all electronic signatures are the legal equivalent of my signature, and I consent to be legally bound by this agreement.*

I am the owner or an authorized agent for the owner of the above-named pet. I have the authority to make medical decisions related to the pet. By signing this Patient Intake Form, I hereby authorize the doctor on duty (and staff the doctor may designate) to administer treatment and medication as is considered therapeutically or diagnostically necessary or appropriate on the basis of findings during the course of evaluation of the above-described animal. I acknowledge that the emergency examination fee is $195. I consent to the release of medical information by EAH. EAH is open 24 hours per day, 7 days per week. I agree that any patient not so removed shall be deemed to have been abandoned. Once this animal has been abandoned, EAH has the responsibility for the animal and will treat or dispose as we deem best. I understand that my animal will receive emergency treatment only and that it may be released before all medical problems are known or treated. I understand that, with any medical or surgical procedure, there are risks involved, including the risk of death. I acknowledge that no guarantee or assurance is being made as to treatment results.*

Treatment Authorization

Treatment Authorization

I am the owner or an authorized agent for the owner of the above-named pet. I have the authority to make medical decisions related to the pet. By signing this Patient Intake Form, I hereby authorize the doctor on duty (and staff the doctor may designate) to administer treatment and medication as is considered therapeutically or diagnostically necessary or appropriate on the basis of findings during the course of evaluation of the above-described animal. I acknowledge that the emergency examination fee is $195. I consent to the release of medical information by EAH. EAH is open 24 hours per day, 7 days per week. I agree that any patient not so removed shall be deemed to have been abandoned. Once this animal has been abandoned, EAH has the responsibility for the animal and will treat or dispose as we deem best. I understand that my animal will receive emergency treatment only and that it may be released before all medical problems are known or treated. I understand that, with any medical or surgical procedure, there are risks involved, including the risk of death. I acknowledge that no guarantee or assurance is being made as to treatment results.

Acceptance of Financial Responsibility

I understand that payment in full is required at the time of service. I understand that EAH staff will provide me with an estimate for recommended services, and acknowledge that it is my responsibility to notify the staff of any financial limitations I might have, so that they are able to tailor the treatment plan accordingly. I acknowledge that an estimate is only an approximation. If the pet requires hospitalization, I agree to make a deposit in advance and pay the balance when the pet is discharged. If I do not pick up the pet at the date and time specified by EAH staff, additional charges will accrue. I recognize that I am responsible for all charges related to the pet, regardless of treatment results and treatment results are not guaranteed. I agree to make payment in cash or by American Express, Visa, MasterCard, Discover, Care Credit, or ScratchPay. I am aware that all delinquent accounts will be transferred to a collection agency.

AI Dictation Consent

To support accurate, timely, and complete medical records, our hospital utilizes a medical dictation software called Talkatoo. This technology is used to document medical findings, treatments, and relevant communications, including in-hospital discussions and medically relevant phone conversations that occur as part of your pet’s care.The use of this software allows our veterinary team to efficiently create medical records while maintaining focus on patient care. Talkatoo securely processes dictated information to generate medical record text and does not replace the professional judgment of our veterinary staff.By signing this form, you acknowledge that you have been informed of, and you consent to, the audio recording and use of Talkatoo for the creation and maintenance of your pet’s medical record during their care at our hospital.

Signature

I understand that payment in full is required at the time of service. I understand that EAH staff will provide me with an estimate for recommended services, and acknowledge that it is my responsibility to notify the staff of any financial limitations I might have, so that they are able to tailor the treatment plan accordingly. I acknowledge that an estimate is only an approximation. If the pet requires hospitalization, I agree to make a deposit in advance and pay the balance when the pet is discharged. If I do not pick up the pet at the date and time specified by EAH staff, additional charges will accrue. I recognize that I am responsible for all charges related to the pet, regardless of treatment results and treatment results are not guaranteed. I agree to make payment in cash or by American Express, Visa, MasterCard, Discover, Care Credit, or ScratchPay. I am aware that all delinquent accounts will be transferred to a collection agency.*

Acceptance of Financial Responsibility

Due to the nature of emergency medicine, EAH needs a resuscitation order for every pet entering the hospital, regardless of severity of illness. The staff of EAH will make every attempt to prevent complications arising from your pet's illness/injury or from procedures carried out in our hospital. However, in some cases there is a risk that your pet may experience cardiopulmonary arrest (CPA). We have requested that you choose whether or not you want us to attempt to revive your pet in the event your pet arrests. By selecting now, we will be able to initiate efforts without delay. CPR is an emergency first aid technique that sustains blood blow to the brain and heart in the event of arrest. CPR involves chest compressions, assisted breathing, and medications. By signing, you also acknowledge that there is no guarantee that the outcome of CPR will be successful. Less than 6% of dogs and less than 20% of cats that experience CPA survive to hospital discharge. Once we have initiated CPR, we will contact you to make further decisions. By signing, you agree that if EAH staff is unable to reach me within 15 minutes after CPR is initiated, and after exercising reasonable medical judgement, further CPR procedures will cease. The cost of CPR is estimated to start around $500.*

Attempt CPR (Cardiopulmonary Resuscitation)Do Not Resuscitate

CPR/DNR Consent

YesNo

Signature*

Pain Medication Consent

To support accurate, timely, and complete medical records, our hospital utilizes a medical dictation software called Talkatoo. This technology is used to document medical findings, treatments, and relevant communications, including in-hospital discussions and medically relevant phone conversations that occur as part of your pet’s care.The use of this software allows our veterinary team to efficiently create medical records while maintaining focus on patient care. Talkatoo securely processes dictated information to generate medical record text and does not replace the professional judgment of our veterinary staff.By signing this form, you acknowledge that you have been informed of, and you consent to, the audio recording and use of Talkatoo for the creation and maintenance of your pet’s medical record during their care at our hospital.*

At Emergency Animal Hospital, we enjoy sharing our patients photos and stories within our hospital as well as online. We request your permission to photograph or video while your pet is with us for these purposes or for educational materials within our hospital. By approving, you give the staff of Emergency Animal Hospital to photograph or video your pet for these purposes. By approving, you release Emergency Animal Hospital and its staff from and and all claims arising out of use of these photos and videos. You understand that there will be no compensation or attribution. You understand that you may revoke consent at any time by providing written notice to Emergency Animal Hospital.*

I agree and grant Emergency Animal Hospital permission to photograph or video my pet for the purposes listed above.I disagree and do not grant Emergency Animal Hospital permission to photograph or video my pet.

Signature*

Photography/Video Consent

Emergency Animal Hospital of Ellicott City Intake Form

Client Information

Pet Information

Medical History

Authorization and Consents

Electronic Signature Consent

Authorizations

CPR/DNR Consent

Pain Medication Consent

Photography/Video Consent