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 *

If your pet has been seen by another vet previously, please have their records sent to us prior to your appointment! Our email address is healthypetalaska1@gmail.com and our fax number is 907-337-4311.

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

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

See if your pet qualifies for "Sick/Urgent Care" Walk Ins or "Wellness" Walk Ins.

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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 boarder 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

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.

Signature *

Date *