New Client Registration Form – Eastern PA Veterinary Medical Center

Owner's Name

Name*

First Last

Please list the phone number we should call to discuss your pet's emergency today*

Secondary Phone Number

Mobile Phone

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The person listed above is over the age of 18 years and is responsible for making both financial and medical decisions for the pet(s) listed below*

If NO – please list the responsible party in the secondary contact below.

Yes
No

Secondary Contact Name

First Last

Secondary Contact Phone

Which Service will you be using?*

Estimated Time of Arrival*

: HH

MM

Reason for Visit*

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)*

Color

Date of Birth or Age*

Special Identification (tattoo, microchip, etc.)

Sex

Date of last rabies vaccines (if known)

Or

Vaccine Status Unknown

Primary Veterinary Hospital Name:*

Primary Veterinarian Name:*

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

How Did You Hear About Us?

If other please specify:

Please choose the appropriate box for your pet:*

Please choose only one

CPR (Cardio Pulmonary Resuscitation) I understand that I am consenting to any and all efforts to be made on my pet's behalf, in the event my pet may require lifesaving intervention such as;cardio pulmonary resuscitation or any other medically necessary life saving treatments/ and or medications deemed necessary by a veterinarian to preserve life. I understand that I am responsible for all fees associated with CPR for my pet. CPR fee range $250 - $750.
DNR - I am consenting to DNR. (Do Not Resuscitate) I do not want my pet to have any lifesaving intervention, in the event my pet may require but is not limited to; Cardio Pulmonary Resuscitation or any other medically necessary life saving treatments or medications, deemed necessary by a veterinarian in an attempt to preserve life. nd Choice

Consent*

Please Read and Sign – Must Be Signed For Hospital To Perform Any Services.
*The Emergency Exam Fee is $125.00*

The doctors and staff are authorized by me to perform diagnostic and therapeutic procedures dictated to be necessary for my pet’s well being. I understand preliminary medical plans will be discussed along with the attendant risks. It is also understood no guarantee will be made as to a result or a cure.

I UNDERSTAND PAYMENT IS DUE IN FULL AT TIME OF SERVICE, WE DO NOT DO ANY BILLING. (Pago al tiempo del servio). Estimates given for treatment may have a broad range to anticipate unforeseen events that can occur with an emergency case. I understand this is only an estimate and agree to be responsible for all charges incurred for treatment performed. A deposit will be taken upon admission to the hospital, the balance is due upon discharge. I certify that I am 18 years of age or older, I am the owner or agent of the owner of the above-described pet and have the authority to execute this agreement.

I agree to the privacy policy.

Please sign your name:*

First Last

Today's Date*

MM

DD

YYYY

Time*

: HH

MM