Fullerton Check-In Date* MM slash DD slash YYYY Have you been here before?* Yes No If so, when? Your Last Name* Your First Name* Primary Contact Date of Birth* MM slash DD slash YYYY (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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (PO Box is not allowed)Your primary phone number*Your secondary phone numberDo 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* Dog Cat Rabbit Bird Ferret Rodent Reptile Breed* Sex* Male Male, Neutered Female Female, Spayed Unknown Color* Birthdate (approximate age is okay)* MM slash DD slash YYYY 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 petResuscitation WishesIf 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 InitialI certify that I am 18 years of age or older.* Initial HereI certify that I am the owner of the animal described here.* Initial HereI 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 HereI 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 HereI understand that all treatments and medications are in addition to the emergency examination fee and agree to pay all the charges incurred.* Initial HereI 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 HereI 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 HereI 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 HereI authorize photos to be taken of my pet to be used for educational and marketing purposes.* Initial HereThank 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
