(865) 523-6886
DOWNTOWN/AFTER HOURS URGENT CARE: 865.525.1167 | NORTHEAST: 865.523.6886 | CHOTO: 865.288.4630

DOWNTOWN: 865.525.1167

NORTHEAST: 865.523.6886

CHOTO: 865.288.4630

Urgent Care Form

If pre-paying, enter: 000-00-0000
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Client Financial and Patient Treatment Agreement

I 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.

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Medical Record Release

We 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:

Pet Information

Pet's Name(Required)
Cat / Dog?
Spayed / Neutered?
Is your pet up to date on vaccines?(Required)
Addtional Symptoms

I 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)