Step 1 of 4 25% I have already checked in.* This form is for clients who have already checked in with us during our walk-in clinic hours. If you have not yet checked in, please contact us before filling this form out. By clicking this box, you acknowledge that you are currently on our guaranteed visit list, or non-guaranteed wait list for the day.Name* First Last PronounsNo Answer Given/UnknownShe/her/hersHim/he/hisThey/them/theirsOtherPhone*May we text visit alerts to this number?* Yes No Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email While not required, it is highly recommended to provide an e-mail address. Visit summaries, invoices, lab results, and doctor communications are most commonly sent through e-mail. Pet Name*Do you authorize Access Veterinary Care to release your pet’s medical records if requested by other clinics, boarding facilities, groomers, and other inquiring parties? Yes No Do you have any budget concerns/constraints for this visit?If you have a specific budget you need to work within (ex. less than $100), please let us know. We try our best to work within your budget concerns, and can direct you to some great resources for additional help! Access Veterinary Care is not a non-profit organization, we do not run on a sliding fee scale, and we do not have in house payment plans. However, we do work with some companies and grant organizations which may help split up the cost of your pet's care or help pay for your pet's care. If you'd like more information about these options, please let us know! Secondary Contact (Optional) First Last Secondary Contact's PronounsNo Answer Given/UnknownShe/her/hersHim/he/hisThey/them/theirsOtherPhoneIs this person authorized to make medical decisions for your pet? Yes No Please let us know how much notice you'll need to return for your visit.*e.g. 15 minutes, 30 minutes, etc. Agreement* I understand that this form does not replace the check-in process, and I must first check-in for my pet to be seen. I recognize that as walk-in urgent care center, Access Veterinary Care staff cannot guarantee wait times. I acknowledge that all appointments are first come first serve, barring any emergencies or end of life procedures. Emergency cases are prioritized at the discretion of the attending veterinarian. I agree to wear a CDC compliant face covering at all times when interacting with staff or inside the building. I verify that I am the legal owner and/or am authorized to make medical decisions regarding the pet to be treated. I attest that all information given is true to the best of my knowledge.