Urgent Care New Client Form

All patients seen at Healing Paws Veterinary Care will be examined, treated, and handled using Fear Free techniques. Patients who are ill or injured will receive a thorough nose-to-tail examination and diagnostic testing in order to determine the best type of treatment for their situation. Payment is due in full at the time of services -we believe in recommending the best for your pet and your family – if you desire an estimate, please request one prior to authorizing procedures being performed. Any patients found to have fleas, or flea dirt will be treated during their examination with Capstar 24 hr flea control at the owner’s cost.

Pet Owner's Name (must be over 18 yrs of age)(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Mobile Phone Number(Required)

Does this number accept texts?(Required)

Yes

Your primary email for the doctor to send your pet's report and discharge instructions(Required)

Emergency Contact / Second Responsible Party in Household(Required)

First Last

Second Party Mobile Phone(Required)

Does this number accept texts?(Required)

Yes

How did you first learn of our hospital?(Required)

Who can we thank for sending you our way?(Required)

If other, please specify(Required)

Current veterinary clinic name and location(Required)

Pet's Name(Required)

Species(Required)

Dog

Cat

Birthdate or Approximate Age(Required)

Breed(Required)

Sex(Required)

Male

Male neutered ("fixed")

Female

Female spayed ("fixed")

Please select all of the following symptoms (even if they are slight) that your pet is experiencing:(Required)

If other, please specify(Required)

Tell us what is your goal for today's visit(Required)

Please list ALL medications, supplements, holistic therapies and over-the-counter products your pet has received in the last 2 weeks. It is very important that you are thorough and detailed in order to avoid drug reactions

Does your pet have any known drug allergies or sensitivities?

Yes

No - none that I know of

If yes, please list(Required)

Approximately when was the last time your pet was seen by a veterinarian and what was it for?

Authorization to Perform Examination/Diagnostics/Treatment: I hereby authorize the Healing Paws Veterinary Care, Inc. staff and doctor to perform an examination. I realize that no guarantee or warranty can ethically or professionally be made regarding outcomes of treatment of medical illnesses or effectiveness of preventative care products and procedures. I have been informed that there are certain risks and complications associated with disease, sedation, anesthesia, and/or any operation/procedure and that while the team at Healing Paws Veterinary Care, Inc has my pet's best interest in mind at all times, sometimes complications occur. I further understand that during the course of the examination, diagnostics, procedures, or treatments, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before treatment or diagnostics are initiated. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I accept that my financial obligations remain regardless of the outcome of treatment.(Required)

I have read and understand this authorization and hereby accept and agree to the terms of the consent for examination pain or relaxing medication treatment as described above. I authorize the doctor and staff of Healing Paws Veterinary Care, Inc. permission to perform examination, tests, and treatments on my pet today and am responsible for the payment of these services. I understand that I will be contacted for further permission if the total of the examination, tests and treatments for my pets is over $500 total today. I do not give permission to perform anything other than examination with treatment for pain or relaxation until I receive the doctor’s recommendations and have signed an electronic treatment plan or paid the invoice via phone. I am responsible for the payment of the examination even if I decline any further tests or treatments. I understand that while the medical team will do their best to perform these procedures the same day if possible, the process of me receiving and returning this treatment plan may delay my pet’s testing, treatments, and discharge time or may require a second appointment to perform these procedures.

CPR/DNR Consent: In the unlikely event that the above-named pet should experience cardiac or respiratory arrest while being seen today, we need to know what your wishes are for your pet. If your pet does experience cardiac or respiratory arrest, we will absolutely contact you. However, your pet's safety and well-being come first, so we need you to direct us here as to your wishes for their care.(Required)

CPR: CARDIOPULMONARY RESUSCITATION - All resuscitative efforts are to be attempted to restore normal heart function and breathing as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR) , I request that the doctor(s) pursues medical care. I understand that this is a cost in ADDITION to any estimate and I agree to pay this fee. The cost of full CPR is typically at least an additional $300 or more and in no way guarantees that my pet will survive their cardiac or respiratory event. Patients who require CPR typically need at least 24 to 48 hours of intensive care and monitoring at a speciality facility following resuscitation. It will be necessary for me to transport my pet to the speciality facility and I will be responsible for the charges for my pet's care at that facility.

I AGREE TO CPR BEING PERFORMED IN CASE OF ARREST. However, if CPR has been performed for 30 minutes, I have not been able to yet be reached by either phone number listed above, and my pet is unable to support cardiac or respiratory function on their own, I authorize the doctor on duty to make the decision to discontinue CPR which may result in my pet's death.

DNR/EUTHANASIA: “DO NOT RESUSCITATE” STATUS WITH PERMISSION TO EUTHANIZE - No cardiopulmonary resuscitation (CPR) efforts will be performed in effort to save my pet if they have cardiac or respiratory arrest. If my pet is actively suffering during its cardiac and/or respiratory arrest, the doctor may give euthanasia solution to ease its passing.

DNR/NATURAL DEATH: “DO NOT RESUSCITATE” STATUS WITH NO PERMISSION TO EUTHANIZE - No cardiopulmonary resuscitation (CPR) efforts will be performed in effort to save my pet if they have cardiac or respiratory arrest. I do not give permission to give my pet euthanasia solution -the medical team should remove airway support if my pet is experiencing cardiac or respiratory arrest

Photo/Name Release: Healing Paws celebrates your pets by using images of them to demonstrate the care and attention that they receive here. Client names are never used in media, pets are never shown suffering, and all photos are intended to help other clients learn how their pets can receive quality vet care. By signing below, I hereby give Healing Paws the right to use the name, video and photograph of any of my pets in connection with its website and any promotional materials in any and all media, including, but not limited to, printed material, internet, social media, and film for display, public relations and marketing. I hereby acknowledge receipt of adequate consideration and waive the right (i) to charge or be compensated for the use of the pictures, and my pet(s)’s name(s) and (ii) to inspect or approve the images prior to any form of usage. I understand that the images may be modified to use as design elements(Required)

I have read, understand, and give permission to the staff of Healing Paws Veterinary Care, Inc. to use images of my pet.

I do not give permission to the staff of Healing Paws Veterinary Care, Inc to use images of my pet anywhere other than their medical record.

Healing Paws Veterinary Care, Inc. Payments Policy

Payment Options: Payment is required in full at the time of services rendered. The only payment types accepted are checks drawn from a local bank (drivers license information required), debit cards, VISA, MasterCard, and Scratch Pay Payment Plan.

Deposits: Non-refundable deposits are required for pets illness/injury appointments, anesthetic procedures, and new client visits.

Estimates: At your request, we will gladly discuss cost of services and/or prepare a written estimate for recommended procedures and treatments. Our goal is to provide your pet with thorough care that also fits your family's needs. We believe in recommending the best for your pet and your family - if you desire an estimate, please request one prior to authorizing procedures being performed.

Returned Checks: We charge a $100 fee for returned checks. This returned check charge and the client balance must be paid in full prior to scheduling any further appointments.

Failure to Pay: In the event you refuse or otherwise fail to make payment owed for services rendered by us in caring for your pet, you are responsible for any and all costs of collection incurred by us, including attorney’s fees, to collect payment(s) from you.

Cancelled Appointments: We ask that if you must cancel or reschedule your appointment you do so greater than 24 hours of your appointment. With the exception of emergency, management deemed extenuating circumstances all appointments that are cancelled or re-scheduled within 24 hrs of the appointment time or are no shows will be assessed a cancellation fee. The cancellation fee must be paid in full prior to rescheduling the next appointment in these situations.

Acknowledgment & Agreement

I represent that any information I provided above is accurate and agree to the terms set forth herein. I understand that payment in full is due to Healing Paws Veterinary Care, Inc. (“Healing Paws”) at the time services are rendered. I authorize Healing Paws to collect payment if I do not pay in accordance with this agreement, and agree that I am responsible for all costs of collection, including, but not limited to, attorney’s fees and court costs. I have been informed that estimates for recommended services/procedures are available upon my request. I further understand that all services performed on my pet will be invoiced according to Healing Paws procedures.(Required)

I have read, understand, and agree to the above statement