Internal Medicine Registration Form

Date and Time of Scheduled Appointment
Date*
MM slash DD slash YYYY
Time
: Hours
Minutes
AM/PM
What Doctor are You Seeing?*
- Dr. Felicia Lew
- Dr. Whitney Nelson
- Dr. Kristen Merrill
Name
First Last
Primary Cell Phone
Secondary Cell Phone
Home Phone
Work Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Information
Name
First
Species
DOB/Age
Breed
Gender
- Male
- Female
Color
Regular Veterinary Clinic
Primary Veterinarian's Name
Authorization for Services
By signing below, I certify that I have read and reviewed the above policies and that I have received and reviewed the procedures and policies handout for the internal medicine services.
Authorization for Services*
I hereby authorize the veterinarian on duty, and the assistants the doctor may designate, to administer treatments as is considered necessary. The attending veterinarian will explain the reason such treatment is considered necessary, it's advantages, possible complications, and possible alternative treatment(s). I consent to release my pet's medical information to my primary veterinarian.
PROFESSIONAL FEE POLICY*
The base fee for the internal medicine consultation and examination is $185.00 ($235.00) if emergency add on). Additional fees will apply if diagnostics, treatments or hospitalization is necessary. An estimate of total cost may be obtained from the staff after discussion of options with the attending veterinarian. A deposit may be required. Fees are to be paid at the time of service. Methods of payment accepted are cash, check, credit card (Visa, Mastercard or Discover) or Care Credit.
CANCELLATION FEE POLICY*
As a courtesy to critical patients waiting to be seen, if you need to cancel or reschedule your appointment please contact our office by 12.00pm the previous business day. You may be subject to a $80.00 fee for same day cancellations or a "no call, no show", which could be subsequently added to any future services.
Reason for today's visit*
Has your pet had any of the following signs?
Please Check all That Apply*
- Vomitting
- Diarrhea
- Discolored Stool
- Change in Appetite
- Change in Water Consumption
- Change in Activity Level
- Change in Behavior
- Changes in Haircoat or Skin
- Sneezing/Coughing
- Difficulty Breathing
Approximately how long has your pet been displaying signs of illness?
What treatments or medications have been tried?
Current medications (list name and strength of drug, and frequency of administration)*
What are your goals for today's visit?*
Cardiopulmonary Resuscitation Status Election Form
ln the event your pet experiences a respiratory or cardiac arrest while in our care, cardiopulmonary resuscitation (CPR) can be administered based on the medical judgement of the veterinarians at Pet Emergency Clinic & Referral Center. CPR includes but is not limited to chest compressions, insertion of a breathing tube with manual ventilation, and administration of emergency drugs. The success of CPR depends on how advanced your pet's condition is.
Please select the ONE option below that best describes your wishes for your pet.*
- I authorize CPR to be performed on my pet should he/she experience a respiratory or cardiac arrest. I understand that the minimum fee for CPR is $250 (above any other previously incurred charges). I understand that the staff at Pet Emergency Clinic & Referral Center will attempt to contact me immediately should my pet require CPR.
- I decline CPR for my pet should he/she experience a respiratory or cardiac arrest. No resuscitation efforts will be made.
Are you already here?
- Yes
- No
Consent
By signing below, I am indicating that I am the responsible owner/agent for the patient. I am also certifying that I am above 18 years of age. I also acknowledge that if I wish to change my patient's resuscitation status in the future, I will be asked to do so in writing.
Owner/Agent Name*
First Last
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Internal Medicine Registration Form

Date and Time of Scheduled Appointment

Patient Information

Authorization for Services

Has your pet had any of the following signs?

Cardiopulmonary Resuscitation Status Election Form

Our Location

Emergency

Internal Medicine