Urgent Care Request Form – Chester Valley Veterinary Hospital

Chester Valley is sad to hear that your pet may be sick and we are here to help. Filling out this form prior to an appointment will help us to understand your pets needs and aid us in appropriately scheduling your pet.

Upon completion of your form we will contact you generally within 24-72 hours (dependent on demand) to set an appointment time or to add you to our stand by list.

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.

If you feel that your pet is emergent or in need of critical care and can not wait for our general contact time we do recommend that you reach out to PET Emergency. Their phone number is 907-274-5636 and they are located at 2320 E Dowling Rd, Anchorage, Alaska.

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

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you a new or existing client? *

New client
Existing client

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

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?

Excessive Drooling *

Yes
No

How long?

Lethargic *

Yes
No

How long?

Concerns with Eating and drinking? *

Yes
No

How long?

Painful *

Yes
No

How long?

Wounds *

Yes
No

Where?

When did it happen?

Excessive Panting *

Yes
No

How long?

Labored Breathing/ Wheezing *

Yes
No

How long?

Sneezing/ Coughing/ Hacking *

Yes
No

How long?

Balding/ Losing Hair *

Yes
No

How long?

Where?

Weight Gain/ Loss *

Yes
No

How long?

Foul Breath *

Yes
No

How long?

Difficulty Urinating *

Yes
No

How long?

Excessive Urination *

Yes
No

How long?

Change in Urine Color/ Odor *

Yes
No

How long?

Urinating outside of the litter box (cat)

Yes
No

How long?

Urinating in the house (dog)

Yes
No

How long?

Dirty/ Smell from Ears *

Yes
No

How long?

Scratching Ears/ Shaking head *

Yes
No

How long?

Discharge from eyes *

Yes
No

How long?

Squinting eyes *

Yes
No

How long?

Vomiting (Food/ Water/ Yellow Bile) *

Yes
No

How long?

How many times per Day/Week/Month

Diarrhea (Liquid/Soft/Bloody) *

Yes
No

How long?

How many times per Day/Week/Month

Lame or Limping *

Yes
No

How long?

New or Unusual Lumps *

Yes
No

Where?

How long?

You qualify for a "Wellness" walk in.

You qualify for a "Sick/Urgent Care" walk in.

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.

Health Certificate

Are you being seen for a "Travel Certificate" or "Health Certificate" to drive across the boarder 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.

Signature *

Date *

Please complete the Urgent Care and Sick form below.

Owner Information

Medical History

Rabies Questions

Health Certificate

Current Medications and Supplements

Other