PATIENT INTAKE FORM – URGENT CARE Step 1 of 4 25% Owner's Name(Required) First Last Phone(Required)Secondary PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Primary Veterinary Hospital Name Check In Date MM slash DD slash YYYY Pet's Name(Required) Species (Canine or Feline)(Required) Spayed/NeuteredYesNoWeight Breed Age Reason for visitCurrent Diseases/Medications OWNER CONSENTThe medical and surgical treatment required for my pet has been described and explained to me. I consent and authorize Vet Partners, their respective owners, agents, and employees to receive, sedate, treat and/or operate, perform CPR on my pet as directed below. I understand that many pets become unstable at any time during treatment. Accordingly:Please start CPR Immediately. I will be responsible for all charges accrued to help my pet. I further understand that there is no guarantee that my pet will stabilize or survive attempts at CPR.(Required)Please SelectI agreeI DO NOT agreeDO NOT PROCEED WITH CPR. I elect DNR- do not resuscitate- in this case, I understand that this can/will result in the death of my pet.(Required)Please SelectI agreeI DO NOT agreePlease provide whatever additional treatments required at this time, regardless of cost. I understand that there may not be time to get an appropriate estimate of care. Therefore, I will be responsible for all charges accrued to help my pet. I further understand that there is no guarantee that my pet will stabilize or survive attempts at treatment.(Required)Please SelectI agreeI DO NOT agreeDO NOT PROCEED WITHOUT FURTHER AUTHORIZATION. Please call me at the number I have listed below prior to starting additional treatments required at this time I hereby release, forever discharge, and hold harmless the foregoing parties from any claim based on such treatment or other medical services.(Required) Please provide humane euthanasia in the event my pet becomes unstable and experiences agonal distress, and I cannot be reached.(Required)Please SelectI agreeI DO NOT agree OWNER RELEASEI understand that sedation, anesthesia, and all medical treatment involves risk to my pet. Vet Partners, their respective owners, agents, and employees use all reasonable precaution against injury. Vet Partners, their respective owners, agents, and employees shall not be held liable in any manner or under any circumstances in connection with any injury, escape, or death of my pet because of the treatment my pet receives. I hereby release, forever discharge, and hold harmless the foregoing parties from any claim based on such treatment or other medical services.(Required)Please SelectI agreeI DO NOT agreeI understand all fees for services provided are expected to be paid at time of services. We do not offer payment plans. Accepted payments: Cash, Care Credit, American Express, Visa, Mastercard, Discover. Personal checks are accepted up to $500 with Drivers License or Passport.(Required)Please SelectI agreeI DO NOT agreeCredit Card Transaction Fees(Required) I understand there is a 3% fee for credit card transactions I verify that I am the owner or guardian of this pet/ animal and will be physically and financially responsible for the pet/ animal that was brought into Vet Partners of Plymouth. I certify that I am eighteen years of age or older. I understand the initial fees and policies. By signing this form, I attest that the above statements are true.(Required)Please SelectI agreeI DO NOT agreeI have read, understood, and agree to the foregoing. I understand that by signing this form I am waiving valuable legal rights. Please complete all the fields below. Owner's Signature (Digital)(Required) Date(Required) MM slash DD slash YYYY In case of an emergency, please call:(Required) Relationship:(Required)
