Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Patient's Name *

Species *

Cat
Dog

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Color: *

Weight *

Main Reason(s) for Visit *

I hereby authorize and direct the veterinarians of Companion Pet Care to perform the procedures and additional diagnostic and/or treatment procedures deemed advisable for my pet. The nature of the procedure(s) has/have been explained to me and no guarantee has been made as to the results or cure. I understand that there may be risk involved in some of these procedures. I agree to pay in full for services rendered including those deemed necessary due to medical or surgical complications or unforeseen circumstances including treatment of various parasites such as fleas, ticks, and worms. Any estimates for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. Procedures may require a deposit be made at admittance and all services must be paid for when your pet is released.

I agree

Please tell us about your pet:

How long has your pet been having their issue they are being seen for today? *

Has your pet been seen for this issue at another clinic? If so, where? *

Has your pet been eating and drinking normally? *

Is your pet on ANY medications? What medication and when was last dose? *

Does your pet have vomiting or diarrhea? *

Is your pet drinking a normal amount of water and urinating normally? *

Is your pet up to date on heartworm and flea preventions? *

Is your pet up to date on vaccines? If given at another clinic, where? *

Resuscitation Orders:

Resuscitation Orders *

DNR: Do Not Resuscitate: In the event of cardiac arrest, there would be NO life-saving intervention of any kind performed including CPR. Your pet would, in essence, be allowed to pass away. After exercising reasonable medical judgment, if it is determined that the patient is suffering and there is no hope for survival, this will act as permission for humane euthanasia if no euthanasia form has been signed. By signing, you are AGREEING to DNR.
CPR: Cardiopulmonary Resuscitation: This may include emergency life-saving measures such as chest compressions, manual ventilation, emergency medications, or intensive nursing care. There will be an additional fee for these services that could range from $100 to $300. Resuscitation would be discontinued if: the owner verbally requests it OR the owner cannot be reached within 15 minutes and the attending veterinarian determines that life-saving measures are no longer going to be successful.

Resuscitation Orders Agreement *

Clear Signature

Owner or designee's signature

Date *

I understand that if my pet needs further care and I return the following day, it is at additional costs. *

I agree

PHOTO CONSENT: We love social media! Do we have your permission to share your pet(s)’ image and story on social media, our website& other forms of related media? Your name and personal information will never be shared. *

Yes. I authorize Companion Pet Care to share my pet’s photo & story.
No. I do not authorize this.

I understand and agree to the above terms and acknowledge that the blood work may be done or fluids may be administered, depending upon my pet’s age and risk factors and that I am responsible for these charges. *

Clear Signature

Signature

Date

Admit Form

Admit Form

Please tell us about your pet:

Resuscitation Orders:

Ready To Visit?

Questions?

Location

Contact Information

Hours