New Client Registration Form – Eastern PA Veterinary Medical Center

**ATTENTION EMERGENCY CLIENTS**

All veterinary emergency hospitals, including Eastern Pennsylvania Veterinary Medical Center, are facing unprecedented increases in caseload. To better establish expectations for your visit, please carefully read the following:

The Emergency Service operates on the basis of the most critical patients being seen and taken care of first. We DO NOT see cases in the order that they arrive – all cases are examined by the triage nurse and are seen in order of severity.
If your pet has a NON LIFE-THREATENING issue, you should be prepared for extended wait times – depending on critical caseload, this could range from 30 minutes to 6 or more hours
If your pet has a non life-threatening issue (skin disease, dental disease, limping, chronic issues, etc), please consider going either to an urgent care facility or waiting for a scheduled appointment with your primary care veterinarian. This will likely be less stressful and faster for you, and will allow our staff to devote more time to critically ill pets and their owners
You must remain on premises (in the hospital or in the parking lot, depending on current COVID restrictions) until you have spoken with a doctor and signed an estimate for treatment. It is impossible for us to accurately estimate how long it will be until your pet is seen. If we are unable to reach you or if you leave the premises, we will move on to the next patient in line.
While we understand that coming to an Emergency Hospital is stressful, there has been a significant increase over the past year in client/owner impatience and anger towards hospital staff. Be aware that verbal abuse or any other threatening behavior from clients towards any Eastern Pennsylvania Veterinary Medical Center staff WILL NOT BE TOLERATED. If you are verbally abusive or threatening to any staff member, you will be dismissed from the hospital premises without service. We are here to help, but you must be patient and polite in order to help us do our jobs.

By completing and signing your intake paperwork, you are acknowledging and consenting to all the above information.

Thank you, and we look forward to helping you and your pet!

Sincerely – The doctors and staff of EPVMC

Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

If you or someone in your home is COVID-19 positive, you are required to have another person that does not live within the household bring the pet to our facility.

Owner's Name
Name*
First Last
Please list the phone number we should call to discuss your pet's emergency today*
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
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*
Breed (if known)*
Date of Birth or Age*
Sex
Primary Veterinary Hospital Name:*
Primary Veterinarian Name:*
Please use the following box to give us any other relevant information about your pet
How Did You Hear About Us?
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 the Hospital To Perform Any Services.
*The Emergency Exam Fee is $140.00*

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

Client Registration Form

Owner's Name

Pet Information