Urgent Care Drop Off Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Client Status(Required)

*Note if you are a new client or a client that has not been to EVH within the past 3 years, there are additional forms you will have to fill out. If we have not seen this patient within the past year there is also a patient history form you will have to update as well.

Client Name(Required)

First Last

Phone number(Required)

Pet's Name(Required)

Species(Required)

Gender(Required)

Age(Required)

Date of Birth if known

Rabies Status(Required)

Pertinent History of Chief Complaint (please answer all pertinent questions to the best of your ability)

What is the primary reason you are bringing your pet to us today?(Required)

How long has this gone on for?(Required)

What medications, supplements, and/or therapies have you initiated? Please be sure to note when the last dose was.(Required)

Are there any other long-term medications, therapies, supplements, etc. that your pet is on?(Required)

Is there anything else we need to know?(Required)

Pet’s overall condition and symptoms

Energy Level(Required)

Appetite(Required)

Thirst(Required)

Urination(Required)

Has there been a color change in urination(Required)

If yes, please describe

Seizures(Required)

If yes, please describe

Bowel movements(Required)

Nausea/vomiting(Required)

Pain/discomfort(Required)

What and when did your pet last eat?(Required)

Consent(Required)

I understand that I am an authorized guardian of the aforementioned pet and am fully authorized to make medical decisions. I understand that I am dropping off my pet as an urgent care dropoff. Urgent cares are reserved for emergencies and are not meant for wellness exams. During an urgent care visit, the focus is ameliorating the current problem and addressing immediate concerns. A wellness visit is a more thorough evaluation of your pet’s health and any change in body and behaviors. I understand that Erickson Veterinary Hospital is not a true emergency hospital and that we will triage your pet to the best of our ability.I understand that due to the unexpected nature of emergency medicine, more critical patients will be examined and treated first. I have provided accurate and up-to-date information regarding my pet’s medical history, current medications, allergies, and other relevant details. I understand that failing to provide accurate and pertinent information can affect the outcome of my pet’s treatment and subsequent care.(Required)

Consent(Required)

I understand all urgent care dropoffs require a minimum deposit of $300. This deposit does not represent the total bill, it is merely to get started to triage your pet. Many emergency cases require extensive lab work, medical interventions, diagnostic procedures, etc. and $300 allows us to initiate the stabilization process.(Required)

Consent(Required)

You will be contacted by an EVH staff member with a treatment plan once a veterinarian has conducted an examination of your pet. It is your responsibility to pick up the phone when you are called. I understand that because of time constraints it may not be a veterinarian that calls me with the initial treatment plan. I understand that if I fail to pick up the phone call, the EVH veterinarians will use their best medical judgment to stabilize your pet and that I will be responsible for any charges incurred. I also understand that in a relatively stable pet, certain procedures may not be able to be performed without authorization for my pet if I fail to pick up the phone call and that I may have to return a different day at additional cost for said procedures. I understand that it is the nature of veterinary medicine that some risks always exist with any type of medical procedures and that I am encouraged to discuss said concerns before procedures are initiated.(Required)

Consent(Required)

I understand that if my pet needs to be sedated that some risk always exists with anesthesia/sedation even in apparently healthy animals including the possibility of death.(Required)

Consent(Required)

I understand that if fleas and/or “flea dirt” are found on my pet EVH has the right to treat at my expense.(Required)

Consent(Required)

I understand that the veterinarians and staff of EVH will make a good faith effort to update me on the status of my pet and changes in the treatment plan. Due to the nature of many medical procedures, there may be circumstances in which changes may be made, such as a different medication administered or an additional diagnostic performed, of which I may not have direct prior knowledge. I authorize the veterinarians of EVH to make such changes without my prior consent, as long as the procedure(s) and treatment(s) retain the spirit and goals of the agreed-upon treatment plan.(Required)

Consent(Required)

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the outcome or results that may be achieved.(Required)

Consent(Required)

You can contact me or my authorized representatives today at the following numbers(Required)

Contact #1 Name(Required)

First Last

Relationship(Required)

Phone number(Required)

Contact #2 Name

First Last

Relationship

Phone number

Contact #3 Name

First Last

Relationship

Phone number

If despite the best efforts of EVH my pet experiences cardiopulmonary arrest (heart stops beating, and breathing ceases), I request the following intervention plan be initiated for them.(Required)

Consent(Required)

I understand that I am responsible to immediately pay all fees that are due at the time my pet is released from the hospital.(Required)

Signature(Required)

Print name(Required)

Date(Required)

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

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