LAASER Registration Form

Owner's Name*

First NameLast Name
Best Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Contact Number is a:*

MobileHomeWorkOther
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner's Date of Birth (Must be over 18)*

MonthDayYear
Date
Secondary Contact

First NameLast Name
Secondary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact's Email Address
example@example.com
Pet's Name*
Pet's Approximate Date of Birth*

MonthDayYear
Date
Pet Species*
Pet's Breed*
Pet's Fur Color*
Pet's Sex*
Do you have pet insurance?*

YesNo
Which pet insurance company?*
What is your Trupanion Policy Number?
Reason for Visit*
Reason for Visit (If this is for an orthopedic surgery, please specify which limb & how long your pet has had this issue).*
Does you pet have any pre-existing medical conditions?*
Is your pet currently on any medication(s) and/or supplement(s)?*

YesNo
Please list all current medication(s) and/or supplement(s) your pet is receiving, including formulation, dose, and frequency given of each. (Example: Prednisone 3mg/ml, 1ml, twice daily)*
What does your pet normally eat? Dry kibble, wet food, fresh food(refrigerated), home prepared cooked(not raw), freeze dried, commercial raw, home prepared raw? Please specify:*
Specifics of diet: please ingredients below; if homecooked list all ingredients and amount fed; as well as, way of cooking(boiled, baked, stewed, etc.) if commercial, (dry kibble or canned) please note brand and amount feeding*
Pet's Primary Care Veterinary Clinic*
What Veterinary Hospital Referred You To LAASER?*
List all veterinarians, vaccine clinics, and/or specialty hospitals where you have taken your pet in the past (please include their phone numbers). Please make note of who your primary veterinarian is in this section. If your pet has been to a specialty hospital please list which department.*
CPR: In the event of an unforeseen catastrophic emergency which leads to cardiac arrest, please choose an option below:*

Yes, please perform CPR (Resuscitate) *If elected, the initial cost of CPR can be anywhere from $600-$1200. *Will be initiated by closed chest compressions and ventilation but can include advanced methods up to open chest compressions as determined by doctor.No, please Do Not Resuscitate my pet (DNR)
How did you hear about us?*

GoogleYelpFacebookInstagramPet Insurance CompanyPrimary VeterinarianSpecialty VeterinarianEmergency VeterinarianFamily/FriendDrove ByOther Urgent Care/General Practice/Emergency/Speciality FacilityMarketingOther
What is their name?*
Payment & Consent Statements*

The information indicated above is correct.I am the owner or authorized agent of the above-described animal and assume financial responsibility for the consultation fee and any additional services performed.I authorize the release of information to the veterinary hospital indicated above and to veterinarians, financial institutions, and insurance providers requesting records and information pertaining to the care received here.If any amounts are not paid at discharge, I understand that LAASER shall commence collection efforts against me immediately. In addition to the amount due at discharge, I will be responsible for the cost of collection (including, without limitation, attorney fees, filing fees, and court costs) and interest at a rate of 6% per annum.I understand that payment is due at the time of service with cash, Visa, Mastercard, Discover, Debit Card, American Express, Care Credit, or third-party financing options available at LAASER.Final charges are based on services provided not based on results or diagnosis.
Did you know? At LAASER, we offer Cherry financing to help make care more manageable.

Learn more here: Cherry

Apply here: Apply for Cherry
By initialing here means that I have read and understood LAASER Code of Conduct . Please click to the link down below for more information. (Initials Here)*
https://laaser.vet/code-of-conduct/
Name*

First NameLast Name
Signature*
Date*

MonthDayYear
Date

I hereby authorize the veterinarians and staff of Los Angeles Animal Specialty Emergency & Rehabilitataiton to examine, prescribe for, and/or treat the above-described pet(s). I assume responsibility for all charges incurred during the care of this animal. I understand that payment is due at the time services are rendered and that a deposit may be required for critical medical needs, procedures and /or hospitalizations. I further acknowledge that Los Angeles Animal Specialty Emergency & Rehabilitataiton is not liable for any lost or damaged personal property belonging either to me or to my pet. In addition, I understand that the premises are monitored by video and audio surveillance for safety and quality assurance, and that incoming and outgoing phone calls may be recorded or monitored for training and quality control purposes. By continuing with services at Los Angeles Animal Specialty Emergency & Rehabilitataiton, I consent to these recordings and monitoring practices.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Los Angeles Animal Specialty, Emergency & Rehabilitation Registration Form