Patient Registration

1
Which Medical Department is Your Pet Needing to See?* This field is required.
Emergency
Specialty Surgery (By Appointment Only)
Diagnostic Imaging - Ultrasound & CT (By Appointment Only)
2
How Can We Help You and Your Pet Today?* This field is required.Emergency Services are available 24/7/365
Emergency: My Pet Is Sick or Injured and Needs Treatment
Euthanasia: End of Life Care
Recheck: My Pet Has Been Seen at this Hospital within the Past 7 Days
3
Imaging Service* This field is required.
Computed Tomography (CT)
Ultrasound
Echocardiogram
Other/Unsure
4
In a Few Words Please Provide the Reason for Visit* This field is required.Example(s): Urinary Issues, Traumatic Injury, Not Eating
5
In a Few Words Please Provide the Reason for Visit* This field is required.Example(s): Quality of Life, Cancer Patient, Not Doing Well, Severe Trauma
6
Owner Name* This field is required.The name of the primary owner of the patient To add additional owners please speak with the front desk once your registration has been submitted
First Name
Last Name
7
Phone Number* This field is required.Please provide the preferred phone number to be contacted
Please enter a valid phone number.
8
Email
example@example.com
9
Owner's Date of Birth* This field is required.
Owner's Date of Birth
10
Pet Owner Address* This field is required.
Street Address
City
Please Select
Please Select
Alabama
Alaska
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
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Does Your Pet Have a Regular/Primary Veterinarian* This field is required.
YESNO
12
Primary/Referring Veterinary HospitalIf applicable, please provide the name of your primary veterinary hospital or doctor
Primary or Referring Veterinary Hospital Name
Veterinarian Name (If Available) - Use N/A if you are unsure
13
Do you authorize this hospital and its staff to communicate via phone, fax, and/or email with the above veterinary hospital regarding the medical care of your pet?* This field is required.
YESNO
14
Pet Name* This field is required.
15
Species* This field is required.
Dog/Canine
Cat/Feline
16
Gender* This field is required.Spay/Neuter Status
Spayed Female
Neutered Male
Intact (Not Spayed) Female
Intact (Not Neutered) Male
17
Breed* This field is required.Example: Domestic Short Hair or Labrador
18
Pet Age * This field is required.Estimated Age is Acceptable
My Pets Estimated Age
Please Select
Please Select
Year(s)
Month(s)
Day(s)
19
Many of the Patients We see are in Critical Condition. To Prevent any Delays in Care in the Event of an Emergency, Please Elect One of the Following:* This field is required.***This can be updated at any point during your visit***
CPR (Cardiopulmonary Resuscitation)
DNR (Do Not Resuscitate)
I am not sure and would like to speak to a Veterinarian first.
20
I want CPR performed on my pet.

Should my pet’s heart stop beating and/or my pet stops breathing, I elect for the PEVSH medical staff to proceed with treatment efforts to resuscitate my pet. I understand I will be contacted as soon as there is a team member available to contact me as the team works on my pet.

I understand that my pet may not respond to CPR or may respond initially and then suffer another arrest later. I understand that my pet may die despite CPR. I understand that if my pet survives with CPR treatments, my pet may still have brain damage, broken ribs, internal organ trauma, and other medical challenges associated with CPR.

I understand that I am financially responsible to pay for CPR treatments. The estimate for initial CPR is $400 to $800. The estimate for the first 24 to 48 hours of veterinary care after CPR depends partially on pre-existing injury or illness and may be an additional $1,500 to $3,000.

**Need to make a change? To update your selection, please click the ‘Previous’ button**
21
I do not want CPR performed on my pet.

Should my pet’s heart stop beating and/or stop breathing, I do not want treatments performed on my pet to resuscitate my pet. I understand that without CPR treatments, my pet will die. I elect to have DNR (Do Not Resuscitate) orders placed on my pet’s record. I understand that someone from the PEVSH medical team will contact me ASAP if this occurs.

**Need to make a change? To update your selection, please click the ‘Previous’ button**
22
I am not sure if I should elect DNR or CPR at this time.

I understand that if my pet’s heart stops beating and/or my pet stops breathing before I get to directly speak with a Veterinarian, the PEVSH medical team will start CPR. CPR will be continued until a PEVSH medical team member is able to speak with me to further discuss my decision.

I understand that I will be financially responsible for the treatments associated with CPR ranging from $400 to $800.

**Need to make a change? To update your selection, please click the ‘Previous’ button**
23
Hospital Policies Acknowledgement* This field is required.
24
Outpatient Hospital Policies Acknowledgement* This field is required.
25
Outpatient Diagnostic Imaging Consent Form* This field is required.
26
Outpatient CT Sedation or Anesthesia Consent Form* This field is required.
27
Ultrasound Sedation Consent* This field is required.I hereby authorize the use of sedation and/or anesthesia for my pet as deemed necessary for today’s diagnostic imaging procedure. I certify that I have the authority to give this consent and do so voluntarily, having been informed of the potential risks and associated costs. I understand that if adequate sedation cannot be achieved to safely complete the ultrasound, the procedure will be discontinued. In such cases, applicable fees will still apply. I understand that my pet will have fur shaved from the area being scanned today. I understand that I will receive only preliminary findings from the diagnostic imaging team today. Final results and any recommended next steps will be communicated to me by my primary veterinarian. I understand that by declining this authorization, the Points East Imaging Service may be unable to complete the requested service or diagnostic procedure.
I consent and agree I decline and understand the above information
28
Euthanasia Consent* This field is required.
29
Social Media Consent* This field is required.I hereby give Points East Veterinary Specialty Hospital permission to take photographs and/or videos of my pet for use in social media, educational materials, promotional content, and other hospital-related media. I understand that my personal information will not be shared, and images will be used in a respectful and professional manner. I acknowledge that I will not receive compensation for the use of these images. I may revoke this consent at any time in writing.
YESNO
30
Pet Owner Signature* This field is required.I hereby authorize the veterinarians at Points East Veterinary Specialty Hospital to examine, prescribe for, and/or treat the above-described pet. I understand and accept that I am financially responsible for all charges incurred during the care and treatment of this animal. By signing below, I acknowledge and agree to the above terms and hospital policies, including those reviewed earlier in this form.
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