Client/Patient Intake

Owner Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Apartment Number (If this is an apartment address)

Primary Phone*

Secondary Phone

Owner's Date of Birth*

Email*

Is There a Second Owner You Would Like to List?

Name

First Last

Email

Phone

How did you hear about us?*

Family or Friend
Referred by Regular Veterinarian
Referred by Another ER Clinic
Internet Search
Shopping Center Sign
Yellow Pages
Previous Visit
Other

Pet Information

Pet's Name*

Pet's Date of Birth*

Species*

Canine
Feline
Other

Breed

Weight*

Color*

Sex*

Male
Male/Neutered
Female
Female/Spayed

Currently Vaccinated?*

Yes
No

What do you feed your pet?*

Does your pet have any allergies?*

Who is your pet’s regular vet?*

Where is the regular vet’s hospital?*

Do you authorize medical records to be sent to your regular vet?*

Yes
No

What is the problem you are being seen here for today?*

Does your pet have any other medical problems? Please explain.

Please list any medications your pet is taking.

Do you have pet insurance?*

Yes
No

If yes, which company?

Payment Consent

Beacon Veterinary Specialists requires payment in full at time of service. A deposit equal to the average of the presented estimate is required prior to treatment on all patients. Any balance is due in full upon the release of your pet. I/We fully understand the payment policy of Beacon Veterinary Specialists and agree to take full financial responsibility for services rendered. We do not accept cash payments.

I understand Payment Consent, Please Initial Here*

Authorization for Medical Treatment:

I, the undersigned, owner of the admitted patient hereby authorize the veterinarians and nursing staff to examine and perform such treatment and/or diagnostics as deemed necessary on the basis of findings during the course of said examination. I understand that I will be presented with a written and/or verbal estimate regarding the desired course of treatment as deemed necessary by the attending veterinarian. I also certify that no guarantee or assurance has been made as to the results that may be obtained. I hereby certify that I have read and fully understand the policies as stated above. If I do not fully understand the policies as out-lined here or have further questions regarding the treatment(s) recommended for my pet, I will request further explanation from the attending veterinarian and/or nursing staff.

Signature of Owner or Responsible, Authorization for Medical Treatment*

Authorization for Emergency Treatment of Critical or Unstable Patients

I hereby authorize the staff or Beacon Veterinary Specialists to perform immediate diagnostics, treatments, and heroic and/or lifesaving procedures for my pet. I understand that the veterinarian will speak with me as soon as possible to inform me of my pet’s condition after assessing and initiating treatment for my pet. I authorize an initial estimate for the emergent care of my pet of $450 - $750. I understand that once my pet is stable additional treatment will likely be necessary and I will be provided with an estimate for the predicted medical plan in addition to the above costs. By my signature, I consent to this estimate and agree to pay these charges.

Signature of Owner or Responsible, Authorization for Emergency Treatment