Emergency Intake Form

Emergency Intake Form

Please fill out all of the information below to the best of your ability. If a question is required and does not apply to you, write 'n/a'. All personal information in this form is for internal use only. We do not sell personal data. Marketing materials will only be sent to those who choose to be on the mailing list. *If you are unable to complete this form online, we have paper forms you can complete when you arrive.*
Client Information

If you are not the owner of the pet (i.e. pet sitter, caretaker), please use the owner's information. There is a box at the bottom that you can include your contact information.
Have you been here before with this pet or have you pre-registered them?*

YesNoUnsure

Primary Owner Name*

First NameLast Name
Secondary Owner Name (if applicable)

First NameLast Name
Phone Number - Please use the best number to reach you at*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you are not the pet owner (such as a family member, pet sitter, caretaker, etc.), please list your name, relationship to the owner, and phone number here:
Email - We will only use this information to send you documents related to your pet's visit. Check the box below if you'd also like to be on the mailing list for hospital updates. *
example@example.com
I would like my email to be added to the mailing list for hospital updates (such as special hours, announcements, etc.)

YesNo
Please list the primary veterinary clinic you would like us to send records to. If you do not have a primary veterinarian, please write 'none'.*
Please include city & state if your veterinarian is not local to the Olympic Peninsula.

Pet Information

Please fill out all of the information below to the best of your ability. If a question does not apply, write 'n/a'.
Name*
How old is your pet? If unknown, how long have you had them?*
Please note if days, weeks, months, or years old
Species*

DogCatOther - Please call our hospital to make sure we can see your pet if it is not a dog/cat
Gender*

MaleFemale
Has your pet been spayed or neutered?*

YesNoI'm not sure
Breed*
If unknown, give your best guess.
Color(s)*

Pre-Registration or Previous Client Shortcut

Although we have most of your information, we need to ensure our info is kept updated. Please answer the questions below.
Name

First NameLast Name
Please list the primary phone number we should use to reach you at:*
Are there any updates you would like made to your account (i.e. new phone number, change in address, secondary owner, change in email, change in primary veterinarian, new pets (that are not being seen today but you would like added to your account)?
Please list the name of the pet you are seeking treatment for today (if you have multiple pets needing care, they will need individual forms):*
If you did not provide this information on the pre-registration form, please enter the following details about your pet:

(If you already provided these details, leave them blank)
Species

DogCatOther - Please call our hospital to make sure we can see your pet if it is not a dog/cat
Pet's birth date or estimated age:
Gender

MaleFemale
Has your pet been spayed or neutered?

YesNoI'm not sure
Breed
If unknown, give your best guess.
Color(s)

CPR STATUS

As many of our patients are visiting us due to illness/injury, we require a 'CPR' or 'DNR' designation for every pet that enters our hospital. Please select a designation below based on the explanations provided for each option. This form will be presented at every visit to keep client wishes as up to date as possible.
All patients treated by this hospital are required to have a Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate (DNR) code. Likely, we will not need this information, but as is common practice in human medicine, we would like you to think about how you would like us to proceed in the unlikely event of an emergency. CPR is the resuscitation of an animal that has stopped breathing or whose heart has stopped beating. Animals that survive cardiopulmonary arrest and have been successfully resuscitated (CPR) are extremely critical and unstable. The likelihood of re-arrest is HIGH and usually occurs within 4 hours of the initial arrest.

The chances of long term “normal” survival is usually less than 10%.

Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel at a specialty hospital, which may require transfer to another facility. The care is costly, and the outcome is uncertain.
Please select one of the choices below. If you have additional questions, please ask a staff member.

CPR - I wish the staff to perform closed-chest CPR (resuscitation) on my pet if my pet suffers from cardiac or respiratory arrest.

Resuscitation (CPR) of a collapsed or unconscious patient is tailored to meet the needs of the individual but may include any or all of the following:
- Establishing an airway via insertion of an endotracheal tube and administration of oxygen or medications through the tube.
- Establishing intravenous access via insertion of an intravenous catheter and administration of fluids and injectable medications through the catheter
- Chest compressions
- Intracardiac delivery of injectable medications
I accept that if the hospital staff is unable to reach me within 10 minutes after the initial CPR procedures, and after exercising reasonable medical judgment, determine that there is no hope for success, the staff will cease further CPR procedures. I understand that despite the best effort of the veterinarians and staff at this facility, even the most successful CPR that may restore my pet’s life may not allow for my pet to regain his/her normal mental and physical health.

If I request such emergency procedures, I agree to be held responsible for veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions. Regardless of my pet's recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. I understand that my pet may not respond to CPR and may die despite CPR. I also understand that if my pet responds to CPR it is likely that he/she will arrest again. I acknowledge that the initial cost of CPR is $500-$750 and that for necessary aftercare, I will transfer my pet to a specialty critical care monitoring hospital that could cost thousands more. I understand that the cost could substantially exceed this
estimate. I understand payment will be required either during my absence or immediately upon my return. I accept this financial responsibility and agree to pay for all services rendered. I understand that the staff will contact me immediately upon the initiation of CPR and if I am not available will proceed at the discretion and under the direction of the attending veterinarian until I can be reached.

DNR - I DO NOT want CPR performed on my pet.

I understand that if my pet suffers from cardiac or respiratory arrest, my pet will
die. I have elected to have a DNR (Do Not Resuscitate) order placed on my pet’s record. I understand that even in this unlikely event, payment will be required for services rendered prior to my pet’s arrest. I accept this financial responsibility and agree to pay for all services rendered.
I choose the following resuscitation designation for my pet:*

CPR - I want my pet resuscitated in case of cardiac/respiratory arrestDNR - I do NOT want CPR to be performed on my pet in the event of cardiac/respiratory arrest
Your Name*

First NameLast Name
Signature*

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Date*

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Consent Form

Please complete the form below to authorize us to treat your pet.
I, the undersigned, attest that I am the owner, or authorized agent for the owner, of the aforementioned animal, and I am so authorized to execute this consent.
- I certify that I am at least 18 years of age.
- I give permission to doctors, staff, authorized agents, or representatives of this hospital to examine, prescribe for, and treat my pets.
- I agree to pay for all services rendered and medications, goods, and supplies when purchased.
- I understand that all fees are due at the time services are rendered and the hospital accepts cash, All Pet Card, Care Credit, Scratchpay, and all major credit cards. I understand that the hospital does not accept Checks for payment.
- I understand the initial consultation fee is $175.
- I understand that a deposit may be required for surgical or medical treatment, at which time I will be presented with an estimate for said treatment plan.
- If I have agreed to an estimated treatment plan and am unable to render payment for services at time of services, I understand that I will be sent to a collection agency and no longer be eligible to receive services at Peninsula Pet Emergency.
- I understand that I am expected to remain respectful to hospital staff and property at all times. I understand that I could be refused services for my pet if I exhibit disrespectful behavior, threaten staff or other clients, use profanity, damage property, or commit assault. Peninsula Pet Emergency reserves the right to contact the Police Department for assistance if I violate this agreement, which may result in criminal prosecution.
- I release this hospital from any and all liabilities.
Your Name*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Emergency Intake Form

Client Information

Pet Information

Pre-Registration or Previous Client Shortcut

Patient History

CPR STATUS

Consent Form