Client Information Form in Garden Grove & Fullerton, CA | Emergency Veterinarian and Animal Hospital in Garden Grove, CA

Date*

Have you been here before?*

Yes
No

If so, when?

Your Last Name*

Your First Name*

Primary Contact Date of Birth*

(This is required by the state of CA for certain medications)

Name of Spouse or Co-Owner

First Last

Address*

Street Address Apartment or space number City State ZIP Code

(PO Box is not allowed)

Your primary phone number*

Your secondary phone number

Do you have an email?*

Yes
No

Your email address*

How did you choose our clinic? (Referral Source)*

Referred by my family veterinarian
Referred by a one of our clients
Google
Yelp
Facebook
Our Website
Saw our sign or building
Been here before

Pet's Name*

Species*

Breed*

Sex*

Color*

Birthdate (approximate age is okay)*

Who is your pet’s family veterinarian or veterinary hospital?*

What is the reason for your visit today?*

Please describe any pre-existing medical conditions or drug allergies for your pet

Resuscitation Wishes:

If your pet experiences cardiac or respiratory arrest while in our care, do you wish for us to perform CPR?

CPR includes artificial respiration, chest compressions, emergency drugs and other lifesaving efforts. The cost for this is approximately $1,000 in addition to all other fees.*

Yes
No

Important Information - Please Initial

I certify that I am 18 years of age or older.*

Initial Here

I certify that I am the owner of the animal described here.*

Initial Here

I authorize the Orange County Emergency Pet Clinic (OCEPC) to treat the animal described here and that this may include diagnostics, an anesthetic and/or surgery.*

Initial Here

I understand that no guarantee of successful treatment is made, and that I will not hold the Orange County Emergency Pet Clinic responsible for my animal’s recovery.*

Initial Here

I understand that all treatments and medications are in addition to the emergency examination fee and agree to pay all the charges incurred.*

Initial Here

I understand that payment is expected at time of service. Payment plans are not offered, except through CareCredit and Scratchpay, which require a credit check and approval by a third party.*

Initial Here

I understand that Orange County Emergency Pet Clinic is not open 24 hours per day. All patients must be discharged before closing each day at 8:00AM (except Sundays and Holidays). If my pet requires further care, I understand that I will need to transfer my pet to my family veterinarian for continued care.*

Initial Here

I understand that if I do not pick up my pet at the time required, Sec. 1834.5 of the CA Civil Code shall deem my pet abandoned and I may incur additional fees and incur criminal charges.*

Initial Here

I authorize photos to be taken of my pet to be used for educational and marketing purposes.*

Initial Here

Thank you for completing this electronic form. Our staff will print this out and have you sign the following in person:

I have reviewed the information above and find it to be correct. I agree to the statements above.

________________________________
Please Print Your Name

________________________________
Please Sign Your Name

________________________________
Today’s Date