Urgent Care Admission Form

Date / Time

Date

Time

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name of Pet *

Dropdown *

Approximate age of pet *

Does your pet have any allergies to medications or vaccines? *

Please describe the illness or injury your pet is currently experiencing. *

What medication(s) does your pet currently receive? *

RISK OF ANESTHESIA: I understand that anesthesia and surgery carry inherent risks of complications including adverse reactions and death. I understand that my pet will receive a thorough physical exam by a veterinarian prior to surgery. I understand that some illnesses or conditions such as pregnancy, being in heat, heartworm disease, or feline viral diseases make surgery riskier and oftentimes cannot be detected on physical exam. I understand that bloodwork performed prior to surgery can help reduce the risks associated with anesthesia. I understand that bloodwork will not be performed on my pet prior to surgery today. I understand that if I wish to minimize the risks of anesthesia by having bloodwork performed, I will need to have all pre-surgical diagnostics and surgery performed at a full-service veterinary clinic. I understand that pre-surgical bloodwork is highly recommended for geriatric pets. *

I agree

Laurel’s House may use my name, and pictures, photographs, or video and/or sound recordings of me and/or my pet on television, on radio, on the internet, in emails, and in stores, news articles, advertisements, or other written or digital materials. I agree that such uses may include education, advocacy, and fundraising. I consent to and authorize, in advance, such use and agree that Laurel’s House does not have to notify me of such use or provide me with other considerations for such use. I waive any rights or privacy and/or publicity I may have in connection with these uses. *

I agree

RIGHT TO REFUSE SERVICE: I understand that Laurel’s House has the right to refuse to perform vaccinations and/or surgery on my pet if it is deemed unsafe to do so due to the health or behavior of my pet. *

I agree

PERMISSION AND RELEASE: I hereby grant permission for my pet to be examined and treated by Laurel's House. I hereby release Laurel’s House, all veterinarians, assistants, and volunteers from any and all claims arising out of or connected with the performance of these procedures or any adverse reactions from vaccinations or other medication. I agree that I have not and will not claim any right of compensation from them, or any of them, or file action by reason of such treatment of such animal or any consequences related thereto. I hereby agree to indemnify and hold Laurel’s House and other involved parties harmless for any damages caused during handling and treatment of the animal. I authorize release of veterinary medical records produced by Laurel’s House to any veterinarian that requests the records. *

I agree

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