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Registration: Drop Off or Procedural Visit
PLEASE FILL OUT THE FOLLOWING THE MORNING OF YOUR PETS SURGICAL, PROCEDURAL, OR HOSPITALIZED VISIT
Client Information and Intake
Please select your pet's reason for visit
(Required)
Hospitalization/Continued Care
Dental
Spay/Neuter
General Surgery
Ultrasound
Acupuncture
Other Procedure
Procedure Name
(Required)
What is your name?
(Required)
First
Last
Pronouns
No Answer Given/Unknown
She/her/hers
Him/he/his
They/them/theirs
Other
What number can we reach you at today?
(Required)
May we text visit alerts to this number?
(Required)
Yes
No
Will someone else be picking up, dropping off, or paying for your pet's visit today?
(Required)
Yes
No
Secondary Contact
What is their name?
First
Last
Secondary Contact's Pronouns
No Answer Given/Unknown
She/her/hers
Him/he/his
They/them/theirs
Other
Phone
May we text this number?
Yes
No
Is this person authorized to make medical decisions for your pet?
Yes
No
In what way will this person be involved with your pets visit today?
(e.g. "call for payment", "call for pick up", "just dropping off", etc.
Let's Get Some Basic Information For Your Pet's Visit!
What is your pet's name?
(Required)
When was the last time your pet ate?
Date/Time?
Kind of Food?
Amount?
Add
Remove
Please list all medications your pet has taken within the last 24 hours
press + to add more medications
Medication Name?
Strength?
When/How much is given?
Add
Remove
How has your pet been doing since we last saw them? Any improvements, new or worsening symptoms, additional concerns?
(Required)
Do you have any questions or concerns about your pet's procedure/treatment today?
(Required)
Any known complications or sensitivities to anesthesia or sedation?
(Required)
Do you have an Elizabethan collar (e-collar, cone of shame) at home?
(Required)
Yes
No
CPR Status
(Required)
In the event that the pet, named above, should experience cardiac or respiratory arrest while in clinic today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of their status? The estimate received today will not reflect costs if resuscitation efforts are administered. Estimated cost for CPR is about $300 - $400. If you change your mind regarding your pets CPR status, please inform your medical team at drop off.
Yes, I agree to CPR being performed in case of arrest
No, I elect a "Do NOT Resuscitate" status in case of arrest
Records and Consent Forms
Please upload any relevant medical records here. Records can also be sent to info@myaccessvetcare.com if not readily available.
Drop files here or
Select files
Max. file size: 1 GB.
Marketing Consent
Do you authorize Access Veterinary Care to use non-specific information and photographs of your pet for the purposes of sharing information and marketing? No identifying information including owners' names, pets' names, or overly unique medical details will be shared.
Yes, I consent to Access Veterinary Care using visual or descriptive material from my pet's visit for marketing purposes
No, I do not consent to Access Veterinary Care using visual or descriptive material from my pets visit for marketing purposes
Treatment Consent and Notification of Anesthesia Risks
(Required)
Just like with humans, there are always risks and complications associated with sedation, anesthesia, and/or any operation/procedure. These risks are rare but can never be completely eliminated. Risks for anesthesia vary, but may include failure of the procedure requiring continued care, allergic reaction, respiratory distress, and other complications up to, and including, death of the patient. The outcome of any treatment and procedure cannot be guaranteed.
Access Veterinary Care's medical team is dedicated to providing the best, safest, and most humane care possible for your pet. Your pet will be monitored closely while under anesthesia.
Surgical complications are rare, but present with any procedure. While some procedures carry a higher level of risk than others, they generally include post-surgical infection, dehiscence (incision opening after procedure), failure of the procedure, hemorrhage (bleeding), other complications up to and including death of the patient. Other risks are more specific to particular procedures (such as jaw fractures for patients with severe dental disease).
During the course of any operation or procedure in clinic, unforeseen conditions may arise that may necessitate the performance of additional procedures. Access Veterinary Care staff will always make a good faith effort to reach the client before additional services are rendered; however certain treatments may be immediately required without advance notice. The veterinarian will make these decisions based on the best interest of the patient and previously noted client wishes.
By acknowledging below, you confirm that you are over 18 years of age, and that you are the owner or the authorized agent for the owner of the animal described above, with the authority to execute this consent. You agree that the nature of these operations or procedures has been sufficiently explained to you and you understand what will be done. You understand that any procedure comes with its own risks and no guarantees for successful treatment can be made. You understand that you are encouraged to discuss any questions or concerns you may have, regarding the applicable pet's medical care, prior to the procedure.
I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.
Treatment Consent and Notification of Anesthesia Risks
(Required)
By acknowledging below, you confirm that you are over 18 years of age, and that you are the owner or the authorized agent for the owner of the animal described above, with the authority to execute this consent. You agree that the nature of these operations or procedures has been sufficiently explained to you and you understand what will be done. You understand that any procedure comes with its own risks and no guarantees for successful treatment can be made. You understand that you are encouraged to discuss any questions or concerns you may have, regarding the applicable pet's medical care, prior to the procedure.
Sedation, Anesthesia, and Surgery:
Should your pet need sedation or anesthesia today, your medical team will discuss this with you prior to treatment. It is at the discretion of Access Veterinary Care staff to accept, refer, or reschedule sedated procedures for any reason including complexity of the case, available time, or preexisting procedure schedule. If your pet is clinically stable, you may be asked to come back for another visit on a different day. If your pet is not clinically stable, you may be referred to an emergency room or another clinic for additional care.
Just like with humans, there are always risks and complications associated with sedation, anesthesia, and/or any operation/procedure. These risks are rare but can never be completely eliminated. Risks for anesthesia vary, but may include failure of the procedure requiring continued care, allergic reaction, respiratory distress, and other complications up to, and including, death of the patient.
The outcome of any treatment and procedure cannot be guaranteed. Surgical complications are rare, but present with any procedure. While some procedures carry a higher level of risk than others, they generally include post-surgical infection, dehiscence (incision opening after procedure), failure of the procedure, hemorrhage (bleeding), and other complications up to and including death of the patient. Other risks are more specific to particular procedures (such as jaw fractures for patients with severe dental disease).
During the course of any operation, treatment, or procedure in clinic, unforeseen conditions may arise that may necessitate the performance of additional procedures. Access Veterinary Care staff will always make a good faith effort to reach the client before additional services are rendered; however, certain treatments may be immediately required without advance notice and the client will be responsible for all associated charges. The Veterinarian will make these decisions based on the best interest of the patient and any previously noted client wishes.
We encourage you to discuss any concerns you have about procedure, treatment, and anesthesia risks with the Access Veterinary Care medical team before treatment is initiated.
I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.
Spay/Neuter Agreement
(Required)
During a sterilization (spay/neuter) procedure the veterinarian or medical team may discover select conditions which require additional attention. These conditions may increase the amount of time your pet is under anesthesia and as a result increase anesthetic risk to your pet. These possible procedures are reflected in your estimate. These conditions include but are not limited to: Pregnancy, retained testicles, umbilical hernias, and female pets in heat. These additional procedures will result in termination of pregnancy, larger or additional incisions, added risk to the patient, and additional charges. These conditions and any other conditions related to the sterilization procedure and visible to the veterinarian or medical staff will be corrected at time of sterilization.
Once your pet is sterilized, a permanent tattoo line will be placed on their abdomen to confirm sterilization.
I have read the spay/neuter agreement and hereby understand and accept the terms included therein.
Estimate Agreement
(Required)
By agreeing to this form, you attest that you received an estimate for veterinary services from Access Veterinary Care. You understand that it is your responsibility to discuss all fees related to the applicable pet's care before services are rendered.
You certify that you have read the provided estimate, understand it, and have had all of you questions answered to your satisfaction and you agree to the costs of treatment.
You understand that additional treatments may be required beyond those listed in this estimate and you will be responsible for those additional services. You accept that your financial obligations remain regardless of the outcome of treatments.
I have read the estimate and estimate agreements and hereby accept the terms included therein.
Payment and Estimates
(Required)
Payment:
Payment is due in full at the time of service. Payment plans are not available through Access Veterinary Care, but are available through approved third-party providers. A list of 3rd party providers can be found on our FAQ page or at myaccessvetcare.com/AFR. The paying party is required to pre-qualify for those services before services are provided.
Estimates:
Access Veterinary Care strives to make our prices as clear as possible. General pricing is available online and pricing is discussed with clients prior to treatment. Estimates are made as comprehensively as possible, with an ideal course of treatment in mind, but may not accurately reflect the final total. Additional treatments may be required beyond those listed in the estimate, and the client is responsible for those additional services. If you indicated a specific budget for your visit, a comprehensive estimate will still be provided with the ideal course of treatment. The medical team will then use their discretion to determine which procedures, diagnostics, and/or treatments would most benefit your pet, taking your budget into consideration.
Treatment Outcomes:
Any treatments or procedures come with their own risks and no guarantees for successful treatment can be made. All financial obligations remain regardless of the outcome of treatment, recommendations for rescheduling, or recommendations for referral.
I understand and agree to the estimate and payment terms
Electronic Signature
(Required)
First Name
Last Name
Date
Comments
This field is for validation purposes and should be left unchanged.
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