"*" indicates required fields Thank you for entrusting your pet’s care to us today. The following information will be used to help our veterinary team accurately complete your pet’s medical history for their visit. We ask that you provide this information 24 hours in advance. Due to the volume of patients seen per day, patients may not be able to be seen right away. If your pet is in critical condition, we ask that you please contact your nearest veterinary emergency clinic immediately. Owner Name* First Last Phone*Email* Pet's Name* Species Dog / Canine Cat / Feline Late arrivals* I have read and understand If you know that you are going to be late, please contact us to see if we are able to keep your appointment. If you are more than 15 minutes late and you do not contact us, your appointment will be automatically cancelled.Checking In* I have read and understand I understand that I will be speaking with a nurse prior to leaving my pet at Memorial Veterinary Clinic, that can take up to ten minutes. I understand that there is a scheduled drop off and pick up time. Who should we contact to make medical decisions today? (only one person will be contacted)* Owner (Named Above) Someone Else (Named Below) Name What are we rechecking today? Have the symptoms worsened, improved, or stayed the same? If your pet needs lab work, what test will we be performing? Will your pet be fasted? Yes No If your pet receives any of the following medications (phenobarbital, thyrovet,trilostane), what time will it be given prior to Day admission? Please write N/A if this question does not apply to you. Are there any additional concerns that you would like the veterinarian to address today?Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations. I understand that financial responsibilities for services are rendered at the time of discharge.* I have read and understand I give Memorial Veterinary Clinic authorization to treat as discussed above.* I have read and understand Social Media/Photo Permission: Do we have your permission to post photos of your pet online?* Yes No Day Admission: Once your pet has been examined by a veterinarian, we will contact you to discuss the next step in your pet's treatment plan. Please be advised that our team is working hard to treat multiple patients per day. We strongly recommend that the designated contact be available by phone throughout the day, as Day Admissions are based on a triage system. In the event that we cannot reach you after your admission and your pet has been examined by a veterinarian.How would you prefer us to proceed?* In the event that I miss the veterinarians call, I prefer to be contacted prior to any additional services being performed beyond an examination and halt treatment. I understand that the veterinarian will wait up to 30 minutes to hear back from me. I understand that by not contacting the veterinarian within the allotted time frame, my pet may be subjected to a delay in treatment. In the event that I miss the veterinarian's call, I authorize the veterinarian to perform ALL diagnostics and treatments that are recommended. In the event that I miss the veterinarians call, I only authorize diagnostics and treatments up to a specific dollar amount. In the event that I miss the veterinarians call, I only authorize diagnostics and treatments up to a specific dollar amount. $250 $500 $750 Other I understand that I am still expected to return the veterinarians call, to discuss the recommended treatment plan. Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.