Urgent Care Form Name(Required) First Last Social Security Number(Required)If pre-paying, enter: 000-00-0000Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Address(Required) 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 Driver's License ID(Required)Driver's License State(Required)AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificClient Financial and Patient Treatment AgreementI agree and understand that I may be required to pay a $200 deposit and/or half of the estimate* at the time of or before treatment of my pet and remaining balance is due at the time services are rendered. For your convenience, we accept Cash, Visa, MasterCard, Discover, American Express and Care Credit.* I understand that any provided estimate of fees for presently planned procedures/diagnostics/etc. is only a best approximation, and the final bill may be less or greater than this estimate.I understand that the treatment of my pet(s) will be conducted with due care and in accordance with highest standards in veterinary medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the veterinarians, agents, or employees of Central Veterinary Hospital. In the event that I default on payment, I will be responsible for all monthly service charges (18%), collection charges (33%), attorney fees or court costs incurred by the hospital. I understand that a written estimate of charges is available within reasonable time of my request.I understand that a recording of the exam will be taken for medical record keeping purposes.I have read and agree to the terms above.Name(Required) Print Date(Required) MM slash DD slash YYYY Signature(Required)Medical Record ReleaseWe will not disclose personal information about you or your pet to anyone except as required by state and local health authorities unless otherwise specified by you. Would you like to consent to the release of medical information for your pet(s) to the following:Primary Veterinarian Clinic(Required)Other Individuals(Required)Pet InformationPet's Name(Required) First Cat / Dog? Cat DogBreed(Required)DoB or AgeGender Male FemaleSpayed / Neutered? Spayed Neutered NeitherPrimary Veterinarian Name & Contact Information(Required)HistoryIs your pet up to date on vaccines?(Required) Yes No UnsureDoes your pet have any allergies?(Required)My pet is on the following medications and/or supplements:(Required)My pet has undergone previous treatments for or had these conditions:(Required)My pet's current diet involves:(Required)SymptomsAppetite Increased Increased somewhat Decreased somewhat Decreased Abnormal NormalThirst Increased Increased somewhat Decreased somewhat Decreased Abnormal NormalActivity Increased Increased somewhat Decreased somewhat Decreased Abnormal NormalUrination Increased Increased somewhat Decreased somewhat Decreased Abnormal NormalAddtional Symptoms Coughing Sneezing Vomitting DiarrheaAdditional DetailsI acknowledge that in the event of an emergency, CPR (cardiopulmonary resuscitation) may be indicated for my pet and that there are additional fees associated with performing CPR, regardless of the outcome. I understand that while CPR can help save a pet’s life, it is not a guarantee of survival. I also understand that CPR has potential risks, such as broken ribs or other injuries. I understand that the veterinary professionals cannot guarantee the outcome. I acknowledge that the decision to perform CPR will be made by the veterinary professionals, should I authorize below:CPR Acknowledgement & Consent(Required) I consent to CPR (cardiopulmonary resuscitation) DNR (do not resuscitate)Signature(Required)
