History Registration: Illness/Injury Visit

THIS SLOT WILL BE HELD FOR 30 MINUTES WHILE YOU COMPLETE YOUR REGISTRATION.

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PLEASE COMPLETE THESE FORMS TO GUARANTEE YOUR VISIT.

YOU’LL BE FORWARDED TO A CONFIRMATION PAGE WHEN YOU’RE ALL DONE!

Consent for Treatment and Acknowledgments

Treatment Terms and Notification of Risks(Required)

Authorized Party:
By agreeing to these conditions, you acknowledge that you are over 18 years of age, and have the authority to grant consent for this patient to receive medical care by Access Veterinary Care staff. You further verify that all given information is true to the best of your knowledge.

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's Urgent Care Clinic team 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.

Your Medical Team:
A Veterinary Assistant will be the main point of contact for your pet’s visit today; however, your pet will have a team of qualified individuals caring for them during their visit. All medical staff members perform various duties at the discretion of the Veterinarian, as determined by their individual skills and knowledge. Your medical team may explain procedure risks, medications, treatments, and answer any questions you may have. If, at any point, you have additional concerns and would like to speak with the Veterinarian, please let your Veterinary Assistant know so they can arrange a supplemental conversation with the doctor. Due to the nature of Urgent Care, wait times to speak with the Veterinarian will vary based on the medical needs of the patients in clinic that day.

I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.

Electronic Signature(Required)

First Name Last Name Date

Name

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History Registration: Illness/Injury Visit

THIS SLOT WILL BE HELD FOR 30 MINUTES WHILE YOU COMPLETE YOUR REGISTRATION.

Client Information and Intake

Secondary Contact (Optional)

Let's Get Some Basic Information on Your (First) Pet!

Patient History: General Information

Prior Diagnoses and Current Medications

Current Concerns/Problems

Toxicity Screening

General Questions

Trauma Event

Wound

Limping/Lameness

Masses, Lumps, and Bumps

Symptom - Diarrhea

Symptom - Vomiting

Symptom - Coughing

Weight Change

Symptom - Change in Drinking Habits

Symptom - Change in Eating Habits

Urinary Concerns

Seizures

Eye and Respiratory Symptoms

Prescription Medication Renewal

Tell Us a Bit About Your Second Pet!