Owner InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Primary Phone*Secondary PhoneDate of Birth Date Format: MM slash DD slash YYYY Email* How Did You Hear About Us?--- Please Select ---Family or FriendReferred by Regular VeterinarianReferred by Another ER ClinicInternet SearchShopping Center SignYellow PagesPrevious VisitOtherPet InformationPet's Name*Date of Birth* Date Format: MM slash DD slash YYYY Pet Speicies*--- Please Select ---CanineFelineOtherBreedWeight*Color*Sex*--- Please Select ---MaleNeutered MaleFemaleSpayed FemaleCurrently vaccinated?*--- Please Select ---YesNoWho is your pet’s regular vet?*Where is the regular vet’s hospital?*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?*--- Please Select ---NoYesIf Yes, Which company?*Payment ConsentBeacon 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.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 PatientsI 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
