Veterinary Emergency Clinic Intake Form
Client sheet
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Email *
Owner First Name *
Owner Last Name *
Street Address *
Town *
Zip Code *
Has anyone in your household been diagnosed with COVID in the past 5 days? *
Have you been to our Genesee St. location in the past? *
Best phone number -Cell phone number we can use this to call you during your visit (please include area code) *
Please enter your Email Address. We use this information to send you a copy of the completed medical record at the end of the visit *
Car make and color *
Pet's name *
Species *
Breed (If your pet is a cat, please write: long hair, short hair or specific breed please) *
Gender *
Spayed/Neutered *
Color *
Age or birthdate *
Approximate Weight *
Which veterinary clinic do you normally go to? *
What problem is your pet experiencing? *
Does your pet have any known health problems? *
Is your pet on any medications regularly? Have you given any human medications or supplements recently? If yes, please list. *
Have you traveled outside of the country in the past 14 days? *
Is your pet experiencing any of the following? (seizures (or history of seizures), eyeball out of socket, hit by motor vehicle, difficulty breathing, not able to urinate, bleeding, and/or unresponsive?) *
 I certify that I hereby give the veterinarians, his/her agents and VEC employees full and complete authority to administer medications and perform testing and procedures which they deem necessary. I understand that all payment is due at time of service. *
Required
Are you the owner of this animal? *
If you are not the owner of this animal, what is their name and what phone number can we reach them at? *
Payment Policy: All fees are expected in full at the time services are rendered. We accept cash, all major credit cards, Care Credit, and Scratchpay.I understand that failure to pick up my pet when ready for discharge may result in it being surrendered to the SPCA for abandonment in compliance with New York State Law. *
Required
Release Agreement: I, the undersigned, certify that I am the owner (or duly authorized agent for the owner) of the admitted animal and that I do hereby give the veterinarian, his/her agents, Veterinary Emergency Clinic employees and representatives full and complete authority to administer anesthesia, and to perform any testing, medical and surgical procedures which they deem necessary. I understand that I am responsible for ALL clinic fees, and that this responsibility continues in the event that the patient fails to recover, and that the fee estimate is subject to change in accordance with the needs of my pet. In the event of outstanding fees, the account will be subjected to an additional collection fee of 33.3% of the delinquent balance. This is based on the treatment estimate provided. *
Required
VEC occasionally shares images and/or descriptions of our pet patients (while keeping owner information private) on digital and social media, for training, marketing, or to enhance veterinary medical knowledge. *
Required
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