Urgent Care Request Form – Chester Valley Veterinary Hospital

About You

Name *

First

Last

Email *

Phone *

Secondary Contact (optional)

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Are you a new or existing client? *

New client
Existing client

Is your pet currently sick? *

Yes
No

About Your Pet

Pet’s Name *

Age or Date of Birth *

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 (chestervalleyvet@healthypetalaska.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.

What brings you in today? *

Current Health Snapshot

To help us understand how your pet is doing, please let us know if you’ve noticed any of the following:

Eating changes (Ex: decreased appetite, refusing food, eating less/more than normal, difficulty chewing, sudden food pickiness.) *

Yes
No

Please describe your concern:

Drinking changes (Ex: drinking more or less than usual, constantly thirsty, emptying water bowl quickly.) *

Yes
No

Please describe your concern:

Vomiting (Ex: food, foam, bile, or blood; frequency and when it started are helpful.) *

Yes
No

Please describe your concern:

Diarrhea (Ex: soft stool, liquid stool, mucus, blood, straining, increased frequency.) *

Yes
No

Please describe your concern:

Coughing, sneezing, or breathing changes (Ex: coughing, wheezing, labored breathing, panting more than normal, nasal discharge.) *

Yes
No

Please describe your concern:

Urination changes (Ex: straining to urinate, accidents in the house, blood in urine, frequent urination, inability to urinate.) *

Yes
No

Please describe your concern:

Lethargy or weakness (Ex: sleeping more than usual, low energy, reluctant to move, difficulty standing.) *

Yes
No

Please describe your concern:

Limping and/or painful (Ex: limping, stiffness, reluctance to walk/jump, crying when touched.) *

Yes
No

Please describe your concern:

Lumps, Bumps, swelling (Ex: new lump, lump growing or changing size, swelling anywhere on the body.) *

Yes
No

Please describe your concern:

Skin Concerns (Ex: redness, hair loss, scabs, hot spots, rash, flaky or irritated skin.) *

Yes
No

Please describe your concern:

Ear Concerns (Ex: odor, discharge, redness, head shaking, ear sensitivity or pain.) *

Yes
No

Please describe your concern:

Itching, scratching and/or chewing (Ex: frequent scratching, licking paws, chewing skin, rubbing face or body.) *

Yes
No

Please describe your concern:

Behavior changes (Ex: hiding, aggression, anxiety, confusion, unusual vocalizing, personality changes.) *

Yes
No

Please describe your concern:

Possible toxin exposure or injury (Ex: eaten medications, chocolate, garbage, chemicals, plants, foreign objects, trauma or fall.) *

Yes
No

Please describe your concern:

Has your Pet traveled to lower 48 (Ex: travel outside Alaska, exposure to ticks, heartworm areas, or new environments.) *

Yes
No

When?

Where?

Are you being seen for a travel or health certificate? (Ex: airline travel, border crossing, relocation paperwork.) *

Yes
No

Date of travel

Form of transportation (air, driving, ferry)

Reason for travel

Traveling Human information:

Name:

Phone:

Alaska Address:

Destination address:

Medications & Vaccines

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: *

Rabies status: *

Current (will provide proof if needed)
Needs vaccination
Under 14 weeks old
Previously vaccinated at CVVH

Safety & Handling

Your pet’s safety — and the safety of our team — is very important to us.

Does your pet have a history of fear, anxiety, aggression, or biting at the veterinary clinic? (Ex: growling, snapping, biting, severe fear, hiding, needing a muzzle, difficulty being examined, or becoming very stressed during vet visits.)

Yes
No

Do you need assistance handling your pet during today’s visit? (Ex: pet is very large, painful, fearful, difficult to lift, or you have physical limitations that make handling your pet difficult.)

Yes
No

If your pet is reactive or easily stressed, please keep them in your vehicle after check-in. A team member will escort you directly into an exam room.

Permissions & Policies

Photo/Video Release: I grant permission to Chester Valley Veterinary Hospital to photograph or record my pet and to use my pet’s image, likeness, or voice for educational, informational, or promotional purposes without compensation. I understand that images or recordings may be edited, published, or distributed without geographic restriction and that I waive any right to royalties or additional consideration. *

Photo/Video Release Authorized
Photo/Video Release Denied

Acupuncture Authorization: I understand that acupuncture may be recommended to address conditions such as pain, gastrointestinal concerns, respiratory conditions, anxiety, or other medical issues. Acupuncture involves the placement of fine needles at specific points on the body to stimulate physiologic responses and may result in temporary soreness or sedation. I authorize or decline the use of acupuncture for my pet as deemed medically appropriate by Dr. Tobiason. *

Acupuncture Authorized
Acupuncture Denied

No Show and Cancellation Policy *

I understand that appointments must be canceled at least two business hours prior to the scheduled time. Failure to provide appropriate notice or arriving more than five minutes late may be considered a missed appointment. Missed appointments or late cancellations may result in a fee and may affect my ability to schedule future services at Chester Valley Veterinary Hospital.

Treatment and Financial Authorization : I authorize the doctors and staff of Chester Valley Veterinary Hospital to examine, diagnose, and treat my pet and to discuss medical findings with me or my authorized representative. I understand that I am entitled to request an estimate of charges; however, I acknowledge that all services provided are my financial responsibility regardless of treatment decisions. An exam fee applies whether or not I proceed with recommended care. I consent to the administration of anesthesia, sedation, diagnostics, medical treatment, or surgical procedures as deemed medically necessary for my pet’s health and safety. I understand that no guarantees have been made regarding treatment outcomes. Payment in full is due at the time of service prior to my pet’s release. Any unpaid balance may be subject to additional collection efforts, and I agree to be responsible for any costs associated with the recovery of outstanding charges, including collection fees, attorney fees, and court costs if applicable. If my pet is not retrieved within ten days of written notice to the address provided, I understand my pet may be considered abandoned and may be rehomed, transferred, or humanely euthanized without relieving me of financial responsibility for services rendered. *

By signing below, I acknowledge that I have read, understand, and agree to the above authorizations, policies, payment requirements, and associated risks.

Digital signature *

Date *

Before you go?

Is there anything important you’d like us to know about your pet?

Email *

Sick / Urgent Care Form

About You

About Your Pet

Current Health Snapshot

Medications & Vaccines

Safety & Handling

Permissions & Policies

Before you go?