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ADMISSION / DROP-OFF CONSENT FORM
"Allow our family to take care of Yours"
Covid-19 Disclaimer
CURRENTLY WE ARE ONLY ACCEPTING CLIENTS THROUGH CONCIERGE CURBSIDE, MEANING THAT NO CLIENTS ARE ALLOWED INSIDE OUR FACILITY WITH THEIR BELOVED PETS. WE ARE SORRY FOR THIS INCONVENIENCE BUT THIS IS TO PROTECT US AND YOU AS WELL DURING THESE TIMES OF PANDEMIA. AS A DIRECT RESULT OF THIS MEASURES, WAITING TIMES MAY BE A LITTLE LONGER THAN USUAL, IF YOU NEED ACCOMMODATIONS LIKE DROPPING YOUR PET AND PICKING UP AT A LATER TIME PLEASE LET US KNOW SO WE CAN WORK WITH YOU.
Pet Owner / Caretaker Full Name ( First and Last)
*
Cell Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
PATIENT INFORMATION
Pet's Name
*
Age / Date of Birth
*
CHIP/ Band /Tattoo or Rabies Tag
Species
*
Dog
Cat
Lagomorph(Rabbit)
Avian (Bird)
Reptilian
Chelonian
Pig
Small MAmmal ( Hamster, Rodent, Etc)
OTHER
Breed
*
Color
*
Specific Markings?
Patient Sex
*
Unknown
Male
Female
Male Neutered
Female Intact
Please describe your pet's lifestyle, type of food, etc ( Caged, Free roaming, indoor, outdoor, etc)
Please read through the following questions, and answer any that may apply to your pet today.
Is your pet Lethargic or Weak ?
*
Yes
No
If Yes, please explain
When it started, be as clear as possible with symptoms
Is your pet Sneezing or Coughing?
*
Yes
No
If Yes, please explain
When it started, be as clear as possible with symptoms
Is your pet eating and drinking?
*
Yes
No
If NO, please explain
When it started, be as clear as possible with symptoms
Is your pet Vomiting?
*
Yes
No
I don't Know
Describe the Vomits
Please give as many details as possible
When Started
Color
Content
How many
Last One
Having Diarrheas
*
Yes
No
I don't know
Describe the Diarrhea
Please give as many details as possible
When Started
Color
IS there blood?
Too much or too little
How often
Last episode
Having Urine issues
*
Yes
No
I don't know
If yes please Explain
be as clear as possible with symptoms
Is your pet Gaining or Losing weight?
*
Yes
No
I don't know
Is your pet Hurt?
*
Yes
No
I don't know
Please Explain
Please give as many details as possible
Limping
Has a wound / injury
Something is bothering
Something Else
SOMETHING ELSE is Happening to my peT ( Please Describe)
Please describe in your own words what seems to be the problem
PET OWNER / GUARDIAN AGREE AND SIGN
I Agree
*
I am the owner/agent for described animal, I authorize and request an exam for my pet. I understand the veterinarian will contact me after he has examined my pet to discuss recommended diagnostic and treatment plan, and will have an initial estimate of charges.I have read, understood, acknowledge and confirm that the information is true and correct.
I consent to Paws and Claws Medical Center taking photos or videos of my pet for medical documentation, case studies, marketing and/or social media use.
*
YES
NO
Treatment Consent
*
I hereby authorize the veterinarian to examine, prescribe for, or treat the above describe pet. I assume responsibility for all charges previously approved verbally, over the phone or in written form and incurred in the care of said mascot. I also understand that all professional fees are due at the time the services are rendered. In the event of non-payment, I agree to be responsible for all costs of collection included and not limited to invoice, attorney and court fees.
PRE-ADMISSION DEPOSIT DISCLAIMER
*
Please feel free to contact us at 786-361-9344 for assistance in filling out your pre-admission form. Receiving this information will allow us to admit you for the examination of your pet(s) in a much quicker fashion. if you would prefer to fill this form in person, please visit us at 3858 SW 137th Avenue, Miami FL 33175.Please understand that it is your financial responsibility to pay for the costs of your pet’s prophylaxis, clinical, surgical or any other form of care. At this time if you agreed to schedule an appointment for your pet’s visitation to our veterinary facility, a non-refundable deposit was collected to secure your spot. We try to accommodate your pet’s appointment on the day and time requested, but if at the time we receive your form, the time and date are already filled, we will reschedule your pet for the closest time and date available, to avoid confusions please call before filling this form and submitting payment for confirm availability. As you can appreciate, there is a tremendous amount of work performed by our Staff in both front and back office to guarantee professional capable staffing for your pet’s visit. Please therefore be advised that it is the policy of the office to charge the non-refundable examination deposit when a client chooses to cancel their appointment once it is scheduled. We therefore urge you to be sure of your schedule, availability, and support before accepting our appointment date. Please be advised that failure to make full payment will delay your pet’s appointment.
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PRE ADMISSION DEPOSIT
$
Free
Quantity
AVIAN AND EXOTICS EXAMINATION
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DOG AND CAT EXAMINATION
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FOLLOW UP VISIT
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EMERGENCY VISIT
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Total
$
0.00
Credit Card Details
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Last Name
Credit Card Number
Security Code
Card Expiration
Drivers License
*
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