Rescue/Pet Shelter Check-In Form – Chester Valley Veterinary Hospital

Rescue/pet shelter name *

Rescue/ pet shelter address *

Address Line 1

Address Line 2

City

State

Zip Code

Rescue/ shelter primary contact *

First

Last

Rescue/ shelter primary contact phone *

Rescue/ shelter primary contact email *

Foster/name of person bringing in pet *

First

Last

Foster/person bringing in pet's phone *

Pet's name *

Date of birth or estimated age

Species *

Breed *

Sex *

Male
Female

Spayed/neutered? *

Yes
No

Color/description

Microchip number *

Has your pet been seen previously by a veterinarian? *

Yes
No

Please have your previous veterinarian send all previous medical history for your pet via email (healthypetalaska1@gmail.com) or fax (907-337-4311) PRIOR to your scheduled appointment. Failure to have previous records prior to a scheduled appointment can result in both a delay in care and a medical records retrieval fee.

Reason for visit *

Ownership declaration: I hereby certify that I am the true and rightful/legal owner of the animal described above, no other person/group/shelter or rescue has any right of property in this animal. I assume full and complete rights, title, interests and decision making for the animal described above. *

I have read and attest to the above statement

Photo/video release: I hereby grant permission to the rights of my pet’s image, likeness and sound of his/her voice as recorded on audio or video without payment or any other consideration to Chester Valley Veterinary Hospital. I understand that my pet’s image may be edited, copied, exhibited, published or distributed and waive any right to royalties or other compensation arising or related to the use of my pet’s image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. *

Permission granted
Permission denied

Acupuncture Authorization: Pet acupuncture can be used to treat a host of issues, from pain, appetite stimulant, GI concerns, URI concerns and even sedation and anxiety. Acupuncture is the process of carefully placing special needles at certain points on the body in order to stimulate the nerves and lymphatic systems, as well as create complex interactions with the fascia layer and release of different chemicals and hormones in the body. This results in reduced pain and inflammation, and increased nerve function. Some patients may be slightly sore after treatment. It is not uncommon to also be more sedate after a treatment. I approve/decline the use of simple acupuncture as deemed fit for my pet by Dr. Tobiason. *

Approve
Do Not Approve

If Approve, Please Initial Below: *

Treatment authorization/payment authorization: I hereby authorize Chester Valley Veterinary Hospital’s doctor(s) and staff to examine my pet(s) and to discuss findings with me or an authorized representative. I understand that I am entitled to an estimate of charges for the care and treatment of my pet(s). I am also aware that regardless of my decision to proceed with the estimated treatment or not I am responsible for an exam fee. I hereby consent to the care and treatment of my pet(s) by the staff at Chester Valley Veterinary Hospital. I give my permission to the administration of anesthesia and surgical procedures as seen fit by the physical in the event of an emergency as well as in the treatment of my pet(s). I understand that an itemized receipt will be presented to me upon the release of my pet(s). I take full financial responsibility of all incurred charges for my pet(s). I also understand that full payment is expected before said pet(s) is released to me. I fully understand that any pet(s) brought to Chester Valley Veterinary Hospital by the above person/persons or authorized representative will be considered abandoned, if the animal(s) is not collected within 10days of written notice to the above address. Upon which time Chester Valley Veterinary Hospital has the rights to adopt it out, sell, or euthanize without prejudice to its claims for fees or services rendered. *

I have read and understand

No show/cancellation policy: I hereby understand that Chester Valley Veterinary Hospital requires all appointments be canceled 2 hours prior to your scheduled appointment. Failure to call and cancel an appointment or arriving 5 minutes late to an appointment will be deemed a “No Show.” A cancellation without appropriate notice or no-show appointment will incur a fee at Chester Valley Veterinary Hospital’s discretion and can result in the refusal of service at this practice. *

I have read and understand

Medical History

Excessive thirst? *

Yes
No

How long?

Is your pet drooling excessively? *

Yes
No

How long?

Is your pet lethargic? *

Yes
No

How long?

Is your pet eating/drinking well? *

Yes
No

How long?

Is your pet experiencing pain? *

Yes
No

How long?

Does your pet have any wounds? *

Yes
No

Where?

When did it happen?

Is your pet panting excessively/experiencing labored breathing? *

Yes
No

How long?

Is your pet experiencing labored breathing/wheezing? *

Yes
No

How long?

Is your pet sneezing/coughing/hacking? *

Yes
No

How long?

Is your pet experiencing any hair loss? *

Yes
No

How long?

Where?

Has your pet experienced weight gain/loss? *

Yes
No

How long?

Does your pet have foul breath? *

Yes
No

How long?

Is your pet experiencing difficulty urinating? *

Yes
No

How long?

Is your pet experiencing excessive urination? *

Yes
No

How long?

Have there been any changes in urine (color/odor)? *

Yes
No

How long?

Is your pet urinating inappropriately (having accidents)? *

Yes
No

How long?

Does your pet have dirty/smelly ears? *

Yes
No

How long?

Is your pet scratching their ears and/or shaking their head? *

Yes
No

How long?

Is your pet experiencing eye discharge? *

Yes
No

How long?

Is your pet squinting? *

Yes
No

How long?

Is your pet vomiting (food/water/yellow bile)? *

Yes
No

How long?

How many times per day/week/month

Is your pet having diarrhea (liquid/soft/bloody)? *

Yes
No

How long?

How many times per day/week/month

Is your pet experiencing any lameness/limping? *

Yes
No

How long?

Are there any new or unusual lumps? *

Yes
No

Where?

How long?

You qualify for a "Wellness" appointment.

You qualify for a "Sick/Urgent Care" appointment.

Rabies Questions

Does your pet have a current Rabies vaccine? *

I have a current Rabies Certificate in hand for when I am seen and if it is expired I understand my pet will be vaccinated during visit for a fee.
My pet’s Rabies vaccine is expired and will need to be revaccinated during visit for fee.
My pet is not old enough for a Rabies vaccine (less than 14 weeks old).
My pet received Rabies vaccine at CVVH and if it is expired I understand that my pet will be revaccinated during the visit for fee.

Are you being seen for a "Travel Certificate" or "Health Certificate" to drive across the border or to fly on a plane? *

Yes
No

Is your pet on any medications? *

Yes
No
Other

Has your pet been to the Lower 48? *

Yes
No

Do you think it is possible that your pet will bite or injure you while in the vet clinic? Please let us know so we can have staff prepared to help. *

Yes
No

Do you feel that your pet may bite or injure a staff member while at the vet? Please let us know so that we can keep all staff and animals safe. *

Yes
No

Do you have any physical limitations that would cause you to be unable to handle your pet inside the clinic? Please let us know so we can have staff prepared to help. *

Yes
No

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

Additional information you think is important for us to know

Upload relevant medical records

Click or drag files to this area to upload. You can upload up to 10 files.

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

Digital signature *

Date *