Owner Information

**Owner First Name** *

**Owner Last Name** *

**Email** *

**Primary Phone** *

**Address** *

City *

State *

Zip Code *

Emergency Contact

**Primary Emergency Contact Name** *

Primary Emergency Contact Phone *

Do you authorize your emergency contact to make urgent treatment decisions if you are unreachable? *

Yes

No

Do you authorize your emergency contact to receive patient information in addition to your primary care veterinarians? *

Yes

No

Patient Information

**Pet Name** *

**Birth Date / Age** *

**Species** *

Dog

Cat

Breed *

**Vaccination Status** *

Current

Past Due

Unsure

**Gender** *

Male

Female

**Spayed/Neutered?** *

Yes

No

Unsure

**Chief complaint for internal medicine consultation** *

**Duration of problem:** *

**What procedure is your pet visiting us for?** *

Consultation Only

Abdominal Ultrasound

Endoscopy

Rhinoscopy

Bronchoscopy

Cystoscopy

Unsure

**Please briefly describe the patient's medical history and any current medications.** *

**Any additional specific questions or requests:**

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing Choice Veterinary Specialists to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

Please check this box if you do not want photos of your pet to be used by Choice Veterinary Specialists for media, educational, or other purposes.

By submitting this form, I hereby authorize Choice Veterinary Specialists to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Choice Veterinary Specialists.

Spam Blocker

Internal Medicine Intake Form