First Name

Last Name

Address

City

State

Zip

Home Phone

Cell Phone

Email

Employer

Work Phone

Best Number to Call

Authorized Party (if other than owner)

Authorized Party Contact Information

Family Veterinarian

Family Veterinary Clinic

*How did you hear about us?

Veterinary referral?
Website?
Yellow pages?
Advertisement?
Video?
Friend?
Street sign?
Social media (Facebook or Twitter)?
Other?

Please indicate where you found our ad OR how you found us if not already listed above.

Are you over 65?

yes
no

Those 65 and over may be eligible for our senior discount.

Pet's Name

Breed

Age

Color

Birthdate

Species

Sex

Female
Male

Is your pet spayed/neutered?

yes
no

Weight/lbs.

Chronic health conditions? (please describe)

Is your pet on ANY medications, pain killers (including aspirin), supplements, or special diet?

yes
no

Please specify, including dosages and frequency

Is your pet on any special diet?

yes
no

If yes, please describe special diet and reason for this diet.

If it becomes necessary during your pet's visit, would you like us to administer CPR?

No, do not resuscitate
Yes, please administer CPR

Method of payment

credit card
check*
cash

other

Personal Check/Credit Card Authorization
We will contact you by phone to obtain driver's license information for your personal check and to obtain your credit card information for billing.

Treatment Authorization and Information/Photo Release
I am the owner or the agent of the owner of the above-described pet and have the authority to execute this agreement. I authorize Alpenglow Veterinary Specialty Emergency Center (AVSEC) (RMVC and/or AACCE and/or AMVS) to examine and treat the above pet. I have read and agreed to the financial policies of AVSEC, RMVC, AACCE, AMVS. I accept full financial responsibility for the pet. I understand that payment for diagnostic tests and treatment that I authorize in writing or verbally will be due at the time my pet is dismissed from the hospital.

If another veterinarian has referred me to this hospital, I understand that they will receive a summary of the care and treatment provided by AVSEC and/or RMVC, AACCE, AMVS in order to ensure that my pet's care can be continued without interruption. I also understand that AVSEC, RMVC, AACCE, AMVS consider the identification of a referring veterinarian by me to be my authorization to release records and information to that veterinarian.

Case information and/or photos may be used in teaching, continuing education, and veterinary literature. I authorize release of case/patient information for such purposes; patient confidentiality will be maintained. In the event of ownership transfer, I authorize the release of medical information to the new owner of this animal.

By submitting this online registration form, I am giving AVSEC authorization to perform stabilization measures on my pet in the event the visit is critical in nature.

Financial Policy
Payment is due as services are rendered. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital. I may pay by cash, personal check, Care Credit, or Visa/Mastercard credit cards. (In order to avoid any misunderstandings, please let us know immediately if these terms are not satisfactory.) Checks will be made payable to one of the following: RMVC, AACCE. AMVS.

By submitting this online registration form, I acknowledge that I accept and understand the financial policy completely. There will be no third party billing regardless of who presents my pet to AVSEC for treatment.

Type full name here as authorized signature

Date

Once our staff has reviewed this online pre-registration form and verified its completion, we will send you a confirmation email that you may print for your records.  If we require more information to complete your registration, we will notify you directly.

Thank you for your trust in the staff at Alpenglow Veterinary Specialty Emergency Center!