Ervets4pets.com - Client Check-In Form

Client Check-In Form

If you have not already done so, please call the staff inside at (919) 781-5145 before you complete this form to let them know that you are here. They will assist you in completing the check-in process.
Owner/Agent of Owner Name
Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Pet's Owner Date of Birth*

MonthDayYear
Date
Driver's License #*
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email*
example@example.com
Co-Owner/ Agent of Owner Information

Please complete the fields below IF you would like to add a co-owner.
Owner/Agent of Owner Name
Owner/Agent Date of Birth

MonthDayYear
Date
Spouse/ Co-owner's Name
Spouse/ Co-owner's Phone
Please enter a valid phone number.
Regular Veterinary Practice Name
Please write None or N/A if your pet does not have a regular veterinary practice. If your pet goes to a chain of veterinary practices (Banfield, VCA, etc) please indicate the city or street name of the practice as well.*
Pet Insurance
Name
Policy Number
Did you have to ring the bell for entry?

YesNo
What is the best way to reach you?
Pet Information
Name*
Estimated Age*
Species*
Breed*
Color*
Gender*
Spayed/Neutered?*
Current on all veterinarian recommended vaccination? *
Vaccinated by a veterinarian?*
Please list any chronic health problems, allergies, current prescriptions, or other special medical information of which we should be aware
I grant permission to Animal Emergency Hospital and Urgent Care to post photos of my pet and a brief description of his/her case on public access websites for educational purposes. I understand that no personal information will be disclosed.

I AgreeI Decline
How Did You Hear About Us?
Select that apply

Social MediaWord of MouthReferring Veterinary PracticeGoogleOther
Are you eligible for Military discount?
Discount is available to current or veteran members of the US Military, National Guard and Reserve that provide a valid military ID and is NOT eligible for immediate family members who reside in the same household.

YesNo
Additional Information
- Unless you notify the veterinarian handling your case that you do not give permission, a copy of your pet's medical record will be available to your regular veterinarian.
- Payment is due at the time services are rendered. We will gladly prepare a written estimate before diagnostics and treatment are performed and after the doctor evaluates your pet. A deposit is required when a patient is hospitalized.
I hereby grant permission to the veterinarians in charge of the care of the pet described above to administer any treatment or anesthetics and to perform any such operations as may be deemed necessary or advisable in the diagnosis and medical care of this pet. I certify that I have read and understand the above information. I certify that I am at least 18 years of age and accept full responsibility for payment.
Owner’s Signature*

Clear
Today's Date*

MonthDayYear
Date
Critical Care Authorization
If your pet has been presented in a critical or life threatening state (i.e. - respiratory distress, active seizures, not breathing/no heartbeat, unconscious, etc.), we will need to assess and stabilize your pet. In order to initiate and/or continue acute care, we will need authorization of an initial estimate of at least $700, due at time of service, to perform immediate critical care procedures. This estimate is only for initial stabilization and does not include continued care such as hospitalization, treatments, medications or follow-up care. The doctors and staff will keep you informed as best as possible while performing life-saving procedures. We will provide you with a written estimate of expected charges for continued care at that time. A deposit will be required for patients remaining in the hospital for continued care. Your signature below indicates that you have read and fully understand the above and are authorizing our doctors and staff to perform critical care stabilization.
Owner's/ Agent's Name*
Pet's Name*
Please select one of the following options:
During emergency treatment if my pet experiences cardiac and/or respiratory arrest and the doctor deems it appropriate*

I authorize resuscitation (CPR) - I am aware that this may cost an additional $800I do not authorize resuscitation (DNR)I am unsure which option to choose for resuscitation, so I leave it up to the veterinarian’s discretion whether or not to attempt resuscitation- I am aware this may cost an additional $800 if resuscitation is attempted
Microchip Policy
Owner’s/Agent’s Signature*

Clear
Should be Empty:

Client Check-In Form

Owner/Agent of Owner Name

Co-Owner/ Agent of Owner Information

Regular Veterinary Practice Name

Pet Insurance

Pet Information

How Did You Hear About Us?

Are you eligible for Military discount?

Additional Information

Critical Care Authorization

Please select one of the following options:

Microchip Policy