Urgent Care Request Form – Chester Valley Veterinary Hospital

Chester Valley is sorry to hear that your pet may be sick and we are here to help. Please fill out the Sick & Urgent Care Appointment request form. Filling out this form prior to coming down to the clinic will help us to more quickly understand your concerns and your pet's needs.

Upon completion of your form, we will contact you promptly to set an appointment time. Please also feel free to text and/or call us at 907-333-6591 to ensure you're scheduled as quickly as possible.

If you are able, we do request that you submit or bring in proof of Rabies vaccination, any relevant records, and a detailed list of all medications, supplements, and vitamins.

Owner Information

Name *

First

Last

Email *

Phone *

Spouse/secondary name

First

Last

Spouse phone

Mailing address *

Address Line 1

Address Line 2

City

State

Zip Code

Is your physical address different than your mailing address?

Yes

Physical address

Address Line 1

Address Line 2

City

State

Zip Code

Are you a new or existing client? *

New client
Existing client

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.

Check all that apply

Military
Policeman
Fireman
Senior Citizen

Pet's name *

Date of birth or age

Species *

Breed *

Sex *

Male
Female

Fixed *

Yes
No

Color/description

Microchip number

Name of previous veterinary office/vaccine clinic

Previous veterinary office/vaccine clinic's phone number

This is so we can get records if needed

Reason for visit *

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

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.

Medical History

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

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

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 having 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 CAT urinating outside of the litter box?

Yes
No

How long?

Is your DOG urinating inappropriately (having accidents inside the house)?

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

Is your pet's Rabies vaccination current? *

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.

*Proof of current Rabies vaccination required at time of visit

Health Certificate

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

Yes
No

Alaska physical address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical destination address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of departure *

Transportation *

Flying
Driving
Ferry
Train

Flying generally requires health certificates to be performed within 10 days of flight.

Driving health certificates are good for 30 days from issue.

Travel purpose *

Vacationing
Moving

Are you traveling with your pet? *

Yes
No

Repeat your name *

First

Last

Person dropping pet off at airport name *

First

Last

Your phone *

Person dropping pet off at airport name phone *

Are you interested in anxiety medication today? *

Yes
No

Are you interested in flea/tick/heartworm preventatives today? *

Yes
No

Has your pet been to the Lower 48 before? *

Yes
No

Current medications and supplements

Is your pet on any medications? *

Yes
No

If your pet is on any medications, vitamins, supplements, or Special Diets please bring a detailed list of what the name, strength, dose, and frequency. This is extremely important, even if your pet is on medications we prescribed.

Please list medications and dosage: *

Other

Has your pet been to the Lower 48 *

Yes
No

When?

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.

Digital signature *

Date *

Please complete the Urgent Care and Sick form below.

Owner Information

Medical History

Rabies Questions

Health Certificate

Current medications and supplements

Other