Emergency Animal Hospital of Ellicott City Intake Form
Client Information
Full Name
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First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Additional Phone Number (If applicable, leave blank if not)
Please enter a valid phone number.
Preferred Phone Number to Contact
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
Please Select
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Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State / Province
Postal / Zip Code
Have you been to EAH previously, even if it was with a different pet?
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Yes
No
How did you hear about us?
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Google/Search Engine
My family veterinarian
Word of mouth/Friend
Social Media
Drive by
Other
Pet Information
Pet's Name
*
Species
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Color
*
Age (years)
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Age (months)
Breed
*
Gender
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Male Intact
Male Neutered
Female Intact
Female Spayed
Unknown
Medical History
Please provide any relevant medical history for your pet.
What is your reason for visiting us today?
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When did the symptoms start?
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Is your pet eating and drinking normally? If not, please describe.
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Is your pet experiencing any vomiting, diarrhea, coughing, or sneezing? If yes, when did it start and how often has it been happening?
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Please list any major medical history/medical conditions, hospitalizations or surgeries your pet may have received in their life:
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Is your pet on any medications, supplements, or preventions? Please list, including the dosage of any medications and the last time received, if so.
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Select the following vaccines that your pet receives and is current on:
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Rabies
Distemper/Parvo (Dog)
Leptospirosis (Dog)
Lyme (Dog)
Bordetella (Dog)
Influenza (Dog)
FVRCP (Cat)
Leukemia (Cat)
Rabbit Hemorrhagic Disease Virus/RHDV (Rabbit)
My pet is not current on, or does not receive vaccines
What diet is your pet on?
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Does your pet require any special handling or do they receive medications for fear or anxiety prior to vet visits?
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Does your pet have any allergies to medications or foods? If yes, please list.
*
Family veterinarian (Please list hospital name, with location if hospital has multiple locations or is not in MD):
*
Additional Comments
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Authorization and Consents
Please carefully review the following authorization and consent forms below and sign if you understand and agree with what is written. Please let us know if you have any questions.
Electronic Signature Consent
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.
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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 $180. 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.
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Treatment Authorization
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.
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Acceptance of Financial Responsibility
CPR/DNR Consent
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.
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Attempt CPR (Cardiopulmonary Resuscitation)
Do Not Resuscitate
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CPR/DNR Consent
Pain Medication Consent
I authorize pain medication to be given to my pet, if indicated, to provide comfort while awaiting examination and/or treatment. Pain medication is estimated to cost $60-180, dependent upon the medication used and the weight of my pet.
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Yes
No
Signature
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Pain Medication Consent
Dictation Consent
Our hospital utilizes Talkatoo, a medical dictation software that may record conversations during your pet's visits and communications, including in-person appointments and phone calls. This technology allows us to improve the accuracy and quality of your pet’s medical documentation. Because Maryland is a two-party consent state, we are required by law to obtain your permission to record any communications. By approving below, you acknowledge and consent to the use of Talkatoo for the recording and transcription of your pet's current and future visits and communications with our hospital, including phone calls. These recordings will be used solely for medical documentation and record-keeping purposes.
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I approve the use of Talkatoo during my pet's visit
I decline the use of Talkatoo during my pet's visit
Signature
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Dictation Consent
Photography/Video Consent
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.
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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
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Photography/Video Consent
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