Fullerton Check-In Today’s Date* MM slash DD slash YYYY Have you been here before?* Yes No If so, when? Primary Contact InformationThe Primary Contact is an individual who is at least 18 years of age, is the owner of the animal, will be responsible for making treatment decisions, and will be financially responsible for those decisions.”Primary Contact Last Name* Primary Contact First Name* Primary Contact TitleMr.Mrs.Ms.MissMx.Dr.Primary Contact Address* Street Address Apartment or space number City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (PO Box is not allowed)Primary Contact Phone Number*Primary Contact Email Address* Primary Contact Date of Birth* MM slash DD slash YYYY (This information is required by the State of CA for certain medications)Secondary Contact InformationThe Secondary Contact is an individual who is at least 18 years of age, is authorized to make decisions in the absence of the Primary Contact, and will be financially responsible for those decisions.”Secondary Contact Last Name Secondary Contact First Name Secondary Contact TitleMr.Mrs.Ms.MissMx.Dr.Secondary Contact Address Street Address Apartment or space number City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (PO Box is not allowed)Secondary Contact Phone NumberSecondary Contact Email Address How did you choose our clinic?Referred by my family veterinarianReferred by a one of our clientsGoogleYelpFacebookOur WebsiteSaw our sign or buildingBeen here beforeReferral's Name 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 Has your pet been vaccinated for rabies?* Yes No Not Applicable Approximate date:* 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 Wishes: If your pet experiences cardiac or respiratory arrest while in our care, do you wish for us to perform CPR?* Yes No 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.Important Information - Please Initial1. 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 Here2. I certify that I am 18 years of age or older.* Initial Here3. I certify that I am the owner of the animal described here.* Initial Here4. 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 Here5. 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 Here6. I understand that all treatments and medications are in addition to the emergency examination fee and agree to pay all the charges incurred.* Initial Here7. 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 Here8. 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 face criminal charges.* Initial Here9. I authorize photos to be taken of my pet to be used for educational and marketing purposes. Yes No Thank you for completing this electronic form. Our team will print this out and have you sign the form in-person: I have reviewed the information on this form and find it to be correct. I agree to the statements above. ________________________________ Primary Contact Print Name ________________________________ Primary Contact Signature ________________________________ Secondary Contact Print Name ________________________________ Secondary Contact Signature ________________________________ Primary Contact Date Signed ________________________________ Secondary Contact Date Signed For Office Use Only:Arrival Date:____________________ Arrival Time:____________________ Entering KOK Initials:___________ Discharge Date:________________ Discharge Time:________________ Discharging KOK Initials: _______
