Los Angeles Animal Specialty, Emergency & Rehabilitation Registration Form
Please note if you have not already, you will still need to contact the front desk staff at (323)-800-8387 in order to book an appointment, transfer from another hospital, are on your way or are waiting in the parking lot.
Which department are you bringing your pet to?
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Emergency & Critical Care
Cardiology
Internal Medicine
Neurology & Neurosurgery
Rehabilitation & Integrative Medicine
Surgery
Dentistry & Oral Surgery
Have you ever brought a pet to LAASER before?
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Yes
No
Has the pet you are bringing been to LAASER before?
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Yes
No
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Owner's Name
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First Name
Last Name
Best Contact Number
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Please enter a valid phone number.
Contact Number is a:
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Mobile
Home
Work
Other
Email Address
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Date of Birth (Must be over 18)
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-
Month
-
Day
Year
Date
Secondary Contact
First Name
Last Name
Secondary Contact Phone Number
Please enter a valid phone number.
Secondary Contact's Email Address
example@example.com
Pet's Name
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Pet's Approximate Date of Birth
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Month
-
Day
Year
Date
Pet Species
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Please Select
Dog/Canine
Cat/Feline
Pet's Breed
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Pet's Fur Color
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Pet's Sex
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Please Select
Female Intact
Female Spayed
Male Intact
Male Neutered
Do you have pet insurance?
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Yes
No
Which pet insurance company?
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What is your Trupanion Policy Number?
Reason for Visit
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Reason for Visit (If this is for an orthopedic surgery, please specify which limb & how long your pet has had this issue).
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Does you pet have any pre-existing medical conditions?
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Is your pet currently on any medication(s) and/or supplement(s)?
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Yes
No
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)
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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:
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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
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Pet's Primary Care Veterinary Clinic
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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.
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CPR: In the event of an unforeseen catastrophic emergency which leads to cardiac arrest, please choose an option below:
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Yes, please perform CPR (Resuscitate) *If elected, the initial cost of CPR can be anywhere from $600-$1200.
No, please Do Not Resuscitate my pet (DNR)
How did you hear about us?
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Google
Yelp
Facebook
Instagram
Pet Insurance Company
Primary Veterinarian
Specialty Veterinarian
Emergency Veterinarian
Family/Friend
Drove By
Other Urgent Care/General Practice/Emergency/Speciality Facility
Other
What is their name?
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Payment/Consent
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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 understand that payment is due at the time of service with cash, Visa, Mastercard, Discover, Debit Card, American Express, Care Credit, Scratchpay or third-party financing.
Final charges are based on services provided not based on results or diagnosis.
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.
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)
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https://laaser.vet/code-of-conduct/
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
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Submit
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