Emergency Patient Intake Form

VCA   S an   F rancisco   V eterinary   S pecialists  

 

Emergency   P atient   I ntake   F orm  

 

 

Provide   t he   f ollowing   i nformation   f or   o ur   r ecords,   a nswering   t he   p rompts   a s   b est   a s   p ossible.   P lease   p rint   c learly.    

 

Today’s   D ate:  

Current   T ime:                                                                                                                                 a .m.   /   p .m.  

PERSONAL   I NFORMATION  

Owner/Caregiver:  

Date   o f   B irth   ( M/D/Y):    

Street   A ddress:  

City/State/ZIP:    

Home   P hone:   (                   )  

Cell:   (                   )  

Alt:   (                   )  

Driver’s   L icense   # :    

Email:  

 

PET   I NFORMATION  

Is   T his   P et   C urrently   a   P atient   o f   V CA   S FVS?:     r Yes       r No        

Reason   f or   V isit:    

Pet’s   N ame:  

Species:     r Dog       r Cat       r Other:  

Breed:  

Age/DOB:  

Sex:     r Male       r Female  

Spayed/Neutered:     r Yes       r No  

Color/Markings:  

Are   V accinations   C urrent?:     r Yes       r No       r Unknown  

Who   I s   Y our   P et’s   R egular   V eterinarian?:     D octor   N ame:                                                                                                                   C linic:  

Please   L ist   A ny   C urrent   M edications   o r   T reatments:  

 

 

How   D id   Y ou   H ear   A bout   V CA   S FVS?   C heck   A ll   T hat   A pply:    

rPrimary   C are   V eterinarian           r Word   o f   M outh           r Advertisement   ( Where?:                                                                                                                                                           )  

rOnline   S earch   ( Where/For   W hat?:                                                                                                                                   )           r Other:    

 

STATEMENT   O F   O WNERSHIP   A ND   C ONSENT:   I   a m   t he   o wner   a nd/or   a gent   o f   t he   a bove   a nimal   a nd   h ave   t he  

I   A m   A ware   o f/  

authorization   t o   c onsent   t o   t reatment   i f   a nd   w hen   i t   i s   n eeded.   B y   s igning   t his   f orm   I   a gree   t hat   I   a m   a ware   o f  

Agree   t o   $ 105   E xam  

and   a gree   t o   p ay   t he   $ 105   e mergency   e xam   f ee.   I   u nderstand   t his   f ee   d oes   n ot   i nclude   t reatment   o r   m edica-­‐

Fee.   O wner/Agent  

tions.   A ny   a dditional   t reatment   o r   m edication   w ill   b e   p resented   t o   m e   f or   a uthorization   v ia   a   c are   p lan.   I   a m  

Initials:   _ _________  

aware   t hat   p ayment   i s   d ue   a t   t ime   o f   s ervice   u nless   a rrangement   i s   m ade   P RIOR   t o   p erformance   o f   s ervice.   I f   I  

agree   t o   m y   p et   b eing   h ospitalized,   I   u nderstand   I   w ill   h ave   t o   m ake   a   d eposit   i n   o rder   t o   b egin   t reatment.  

 

By   s igning   t his   a greement,   I   a uthorize   V CA   S an   F rancisco   V eterinary   S pecialists   s taff   t o   p rovide   c are   a nd   p erform   a ny   t reatment,  

including   t he   a dministration   o f   a nesthesia   a nd   s urgical   p rocedures   t hey   c onsider   r easonable   a nd   n ecessary   f or   m y   a nimal,   a nd   I   c on-­‐

sent   t o   a ny   s uch   s ervices.   I   u nderstand   t hat   w ith   a ny   m edical   o r   s urgical   p rocedures   t here   a re   a lways   r isks   i nvolved,   i ncluding   d eath,  

and   t hat   n o   w arranty   o r   g uarantee   i s   b eing   m ade   a s   t o   t he   r esults   o r   c ure.  

 

I   u nderstand   t hat   I   m ust   c ome   i n   a nd   c ollect   m y   a nimal   b efore   c lose   o f   t he   n ext   b usiness   d ay   o nce   n otified   t o   d o   s o.   A dditional  

charges   w ill   a ccrue   i f   m y   a nimal   i s   n ot   c ollected   o n   t he   d ay   h e   o r   s he   i s   r eady   t o   b e   r eleased   f rom   t he   h ospital.   I   w ill   b e   r esponsible  

for   a ll   c harges   i ncurred.   I   u nderstand   t hat   a ll   v eterinary   s ervices   a re   t o   b e   p aid   f or   a t   t he   t ime   s uch   s ervices   a re   p rovided.   A   f inance  

charge   o f   1 .5%   ( 18%   p er   a nnum)   w ill   b e   c harged   o n   a ll   u npaid   i nvoices   b eginning   3 0   d ays   f rom   t he   i nvoice   d ate.   A ll   u npaid   c hecks  

and   d elinquent   a ccounts   w ill   b e   t ransferred   t o   a   c ollection   a gency.  

 

 

 

 

Owner/Authorized   C aregiver   S ignature   ( Required):   _ _______________________________________________   D ate:   _ _____________  

 

Office   U se   O nly  

Wt:  

Temp:  

HR:  

Resp:  

MM:  

CRT:  

 

Verified   b y   ( Office   U se   O nly):   _ _________