Coastal Animal Referral Emergency
Intake & Registration Form
If filling this form out remotely, please call us at 757-703-0199, to see when we can triage your pet. This is not an appointment request form. Completion of this form does not guarantee service nor an appointment.
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Client Expectations: Coastal Animal Referral Emergency views Veterinary care as a partnership between you (the client), the Primary Care Veterinarian, and our medical team. We will do our best to provide a range of diagnostic and management plans and abide by the approach selected by the client, while also considering what we feel is best for the patient. Your pet will receive safe, high-quality Veterinary care regardless of client age, color, disability, gender, gender identity expression, national origin, race, religion or sexual orientation.
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Client Responsibilities: Providing accurate information about your pet’s health and medical history. Providing accurate information regarding all responsible parties. Being honest about your budget so that we can work with you to provide the best care for your pet, within your budget. Asking the medical team for clarification when you do not understand medical terms or instructions about your pet’s plan of care. Following your pet’s plan of care after discharge from the hospital. If you are unable/willing to follow the plan of care, you are responsible for telling your care provider, who will explain the potential medical consequences of not following the recommended plan. Acting in a manner that is respectful towards other clients, clinicians, students and hospital staff. Following the Hospital’s rules and regulations, including respect of Hospital property. Meeting your financial obligation for the hospital services provided, including the initial examination, and associated fees unless otherwise specified at the time of visit.
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Medical Care Disclosure
This page serves as a notice to inform you that we do not have continuous staffing outside of the listed hours. In accordance with State of Virginia Law, Act 54.1-3806.1, effective July 1, 1988, Veterinary practices admitting patients to their facilities must disclose hours of continuous medical care and retain written documentation of owner signature.
CARE's hospital operating hours are limited, running from 8am Friday- 9pm Monday. CARE is closed Tuesday, Wednesday, and Thursday. If your pet requires care outside of our scheduled hours, CARE will arrange a referral to another hospital and it is the owner's responsibility to transport their pet. Please be advised that we do not offer transportation services. Additionally, our hours and availability may be subject to change during holidays.
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I have read and understand the above disclosure form.
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What you can expect: To receive high-quality, compassionate veterinary care. To participate in and make decisions about your pet’s care, including declining care. Your pet’s medical team will explain the potential medical consequences of declining the recommended treatment. To have your pet’s illness, possible treatment plans, and potential outcomes be explained in a manner you can understand. To have communication provided to your Primary Care Veterinarian. To receive written and verbal information about follow-up health care at the end of your pet’s visit. To have private and confidential treatment plans, communications, and medical records for your pet. To have any concerns or complaints addressed.
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Pet's Name
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First Name
Last Name
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Has the pet been a patient in this hospital?
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No
Yes, BUT I need to change my information(phone, address, etc)
Yes, and my information has NOT changed since my last visit
Not sure
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Owner's Information
Parent's Name
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First Name
Last Name
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Primary Owner's Date of Birth (Required by DEA for Prescriptions):
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Month
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Day
Year (19xx/20xx)
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Address
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Street Address
Optional - Street Address Line 2
City
State / Province
Postal / Zip Code
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
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Optional - Second Authorized Contact:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Primary Owner
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Patient Information
Species
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Cat
Dog
Other
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Breed
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Sex
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Male
Female
Male Neutered
Female Spayed
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Pet's Date of Birth
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Month
-
Day
Year (19xx/20xx)
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Color
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Rabies Status:
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Rabies is up to date
Rabies is not up to date
I don't know
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Today's Primary Concern:
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Select if your pet has a history of the following:
Fear
Anxiety
Aggression
Biting
None of the above
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History of Allergies to medication:
Leave blank if Not Applicable
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Current Treatments/Medications
Please include dosages. Leave blank if Not Applicable
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History of Chronic Health Conditions and/or Surgeries
Leave blank if Not Applicable
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Do you have Pet Insurance?
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Yes
No
If yes:
Carrier
Policy Number
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Primary Veterinary Clinic:
blank
City and State:
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We encourage open communication about all medical decisions made for your pet and request that all clients complete a resuscitation directive upon arrival, regardless of the severity of illness/injury their pet is experiencing. The doctors and staff at CARE will make every effort to prevent complications arising from your pet’s illness/injury or procedures performed in our hospital. Unlike humans, the percentage of pets that fully recover after receiving CPR is typically less than 5%. Please select one of the following options:
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Do Not Resuscitate – DNR (no CPR will be performed) This option is always an acceptable choice based upon your beliefs and needs. In the event your pet is suffering, humane euthanasia may be performed.
Attempt Resuscitation (CPR will be initiated and all efforts will be made to resuscitate your pet. Costs associated with CPR are $800+ in addition to your estimate).
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I certify that I am the owner or authorized agent of the above-mentioned pet and am at least 18 years of age or older.
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Coastal Animal Referral Emergency does not accept payment plans or bill for services and all payment is due, in full, at time of services rendered. Accepted payment methods include Cash, Debit, Visa/Mastercard, Discover, American Express and Care Credit.
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I consent to receive text messages from CARE. Message rates vary. Not all carriers are covered. Standard message and data rates apply. You may update your preference, and cancel your consent, by notifying us at any time or by replying STOP to any text message you receive from us.
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We are always looking for cute and inspirational photos to post on our website or Facebook! If we take a picture of your adorable fur baby, do you give us permission to use it publicly?
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Yes
No
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Our veterinary services utilize ScribbleVet, a tool from Kairo Care,Inc., which records your pet's appointments for improved clinical documentation. We need your consent to proceed with the recording. Acknowledging and signing this document, you agree that your vet appointments may be recorded. Usage Rights: You grant us permission to share these recordings, and any other materials you choose to provide, for the purpose of improved clinical documentation. Age Confirmation & Understanding: You affirm that you are at least eighteen years old, and that you understand and accept the terms. We are committed to providing the best care for your pet in a manner comfortable for both of you.
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Signature
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