Patient Intake Form

Patient Intake Form

Please fill out the intake form below. Once you arrive to the hospital your pet will be added to the waitlist.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Owner Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Secondary Contact

First NameLast Name
Secondary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Patient name
Birthdate of Patient
Gender (Male or Female)
Spayed, Neutered, or Intact
Species (Dog, Cat, Rabbit, etc)
Breed
What is the name of the vet hospital where you take your pet for primary care? Write N/A if you don't have one.
Is your pet up to date on vaccines?
Reason for Visit
Current Medications (please list all): PLEASE BRING ALL MEDICATION WITH YOU TO YOUR VISIT
Any health problems that are currently being treated
Treatment Consent
I HEREBY AUTHORIZE Mason Dixon Animal Emergency Hospital (MDAEH) to examine and treat the patient described above medically and/or surgically. I understand there is no guarantee of successful treatment. I also consent to the administration of such anesthetics as are necessary, and surgical procedures of an emergency nature. I hereby release the doctor and assistants from any and all claims. Except claims of negligence, arising out of, or connected with, the performance and his/her treatment. I accept financial responsibility for the treatment of the above-named patient and I understand that payment in full is due upon release of this patient from the facility, or when service is otherwise completed. In the event that emergency treatment is required and I cannot be reached, I authorize the doctor and assistants to perform such medical and surgical treatment as necessary to preserve the life of the patient until I can be contacted for further authorization. All records will be shared with your primary care Veterinarian at time of discharge. To provide the best service, and focus 100% of our attention on your pet, we use an AI note taking platform. This tool is HIPPA compliant and will transcribe conversations into medical notes. As a client of MDAEH, you are consenting to audio recording while in the building for the sole purpose of medical record-keeping. You can expect to get an update from a Veterinarian at any time if the health status of your pet changes. Please be available so that you can be reached to authorize further treatment. As a hospital we round cases every 12 hours beginning at 7am and 7pm. During that time the Veterinarian on duty will be unable to take calls. Recommended call times to speak with a veterinarian are before rounds begin, however we cannot guarantee an exact time that the Veterinarian will be available to discuss your pet's care.. In addition to speaking with a Veterinarian, you will be able to receive updates from a veterinary technician once per 12-hour shift (7:00 am - 7:00 pm and 7:00 pm - 7:00am).
I approve the treatment consent document
Financial Consent
Our exam fee is $159. We offer payment options with Care Credit, Scratch Pay, and All Pet Card. Payment is due at the time services are rendered, and I understand that failure to pay may result in collection fees, added interest, and/or civil or criminal complaints. You agree to receive calls, text messages, and emails from MDAEH and its partners. These messages may contain details about products, services, and debt collection in case of unpaid bills. These messages may be sent using automatic systems or recorded voices. Standard message and data rates may apply. You can opt out at any time by contacting us.
I approve the Financial consent document
I understand that any personal items left in the hospital, such as towels, toys, blankets, etc. may not be returned to me, and MDAEH will not be held liable for such items.
Media Release Consent
Mason Dixon Animal Emergency Hospital to use pictures of myself and/or my pet(s) and all future pets for the purposes of clinic brochures, clinic website, promotional purposes such as Facebook, and/or educational purposes. I understand that once my consent is given, it remains in effect permanently.
Media Consent
Emergency Triage Protocol
I understand the nature of MDAEH is to provide emergency-based care. All patients will be triaged by a veterinary technician upon arrival, and patients will be seen by a veterinarian according to the triage level protocol. I further understand that due to the large volume of patients being seen, I may experience a wait.
I understand the triage protocol
Cardiopulmonary Resuscitation (CPR) Authorization

Understanding cardiopulmonary arrest and CPR
Just like humans, dogs and cats rely on their heart and lungs to deliver oxygen and nutrients throughout the body. Cardiopulmonary arrest (CPA) occurs when the heart stops beating effectively and breathing stops. Without immediate intervention, CPA rapidly becomes fatal.

What is CPR?

Cardiopulmonary Resuscitation (CPR) is an emergency procedure performed when a patient experiences cardiopulmonary arrest. The goal of CPR is to restore circulation and breathing and give the patient the best possible chance of survival.

CPR may include:

Chest compressions to circulate blood throughout the body
Airway management, including placement of an endotracheal tube
Ventilation to provide oxygen to the lungs
Emergency medications to support heart and circulatory function
Defibrillation in rare cases where a shockable heart rhythm is present
Advanced monitoring to evaluate heart rhythm, blood pressure, oxygenation, and response to treatment
Important Information About CPR

While our medical team is trained in advanced CPR techniques and will make every effort to achieve a successful outcome, CPR is often unsuccessful despite appropriate treatment.

Current veterinary studies show that:
- Most patients experiencing cardiopulmonary arrest do not survive to discharge from the hospital.
- Approximately 5% to 7% of dogs survive to hospital discharge following CPR.
- Approximately 1% to 19% of cats survive to hospital discharge following CPR.
- Survival rates vary depending on the underlying disease process, anesthetic status, overall health, and whether the arrest was witnessed and treated immediately.
- Patients that are successfully resuscitated may require intensive hospitalization and ongoing critical care.
CPR Authorization

Please indicate your wishes should your pet experience cardiopulmonary arrest during hospitalization.
CPR Authorization
I understand that CPR and post-resuscitation critical care can result in additional medical costs. I authorize emergency treatment and understand that charges will be discussed as soon as reasonably possible.
I have read and understand the information above regarding cardiopulmonary arrest and CPR. I have been given the opportunity to ask questions and understand that no guarantee of survival or recovery can be made.
Signature Below
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Patient Intake Form

Cardiopulmonary Resuscitation (CPR) Authorization

What is CPR?

CPR may include:

Current veterinary studies show that:

CPR Authorization