New Client Form - Urgent Paws Vet Clinic

Your Information

(*) Indicates Required Field

Name(Required)

First Last

Phone(Required)

Alternative Phone

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Occupation

Spouse or Co-Owner

First Last

Phone

Alternative Phone

Your Pet’s Information

(*) Indicates Required Field

Pet #1

Pet's Name(Required)

Type(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Age(Required)

Sex(Required)

Male

Female

Spayed / Neutered(Required)

Yes

Pet #2

Pet's Name

Type

Dog

Cat

Other

Breed

Color

Age

Sex

Male

Female

Spayed / Neutered

Yes

Referral Information

(*) Indicates Required Field

Marketing

How did you hear about us?

Friend

Internet

Phone Book

Drive By

Doctor

Other

Doctor's Referral

Doctor's Name(Required)

Hospital(Required)

City / Town(Required)

State / Province(Required)

Doctor's Phone(Required)

Life Support Directive

All patients treated by this hospital are required to have a Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate (DNR) code. Likely, we will not need this information, but as is common practice in human medicine, we would like you to think about how you would like us to proceed in the unlikely event of an emergency. CPR is the resuscitation of an animal that has stopped breathing or whose heart has stopped beating. Animals that survive cardiopulmonary arrest and have been successfully resuscitated (CPR) are extremely critical and unstable. The likelihood of re-arrest is HIGH and usually occurs within 4 hours of the initial arrest.The chances of long term “normal” survival is extremely low and may be as little as 5%.

Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel at a specialty hospital. The care is costly, and the outcome is uncertain.

Please select one of the choices below. If you have additional questions, please ask a staff member.

GREEN – CPR – I wish the staff to perform closed-chest CPR (resuscitation) on my pet if my pet suffers from cardiac or respiratory arrest. I understand that my pet may not respond to CPR and may die despite CPR. I also understand that if my pet responds to CPR it is likely that he/she will arrest again. I acknowledge that the initial cost of CPR is $400-$500 and that for necessary aftercare, I will transfer my pet to a specialty critical care monitoring hospital that could cost thousands more. I understand that the cost could substantially exceed this estimate. I understand payment will be required either during my absence or immediately upon my return. I accept this financial responsibility and agree to pay for all services rendered. I understand that the staff will contact me immediately upon the initiation of CPR and if I am not available will proceed at the discretion and under the direction of the attending veterinarian until I can be reached.

RED – DNR – I DO NOT want CPR performed on my pet. I understand that if my pet suffers from cardiac or respiratory arrest, my pet will die. I have elected to have a DNR (Do Not Resuscitate) order placed on my pet’s record. I understand that even in this unlikely event, payment will be required for services rendered prior to my pet’s arrest. I accept this financial responsibility and agree to pay for all services rendered.

Life Support Directive Response(Required)

Green – CPR

Red – DNR

Photograph and Video Release: There may be times where we would like to share a photo or video of your pet with our social media sites (including but not limited to our website, Facebook, Instagram, etc.) Please select your wishes below:(Required)

I hereby grant permission to use my pet(s) photograph or video on the UPVC website, social media platforms, promotional materials, etc., without compensation. Materials will become property of the hospital.

I decline the use of my pet(s) photograph or video on any UPVC social media, website, promotional materials, etc.

Notification Settings – We use text messages and emails to communicate appointment reminders and occasional emergency closure notices. Please make your selection below.(Required)

I consent to all text and email notifications at the above primary cell number and email.

I consent to email notifications ONLY.

I consent to text notifications ONLY.

I decline both email and text notifications. I am aware I will not receive any appointment or closure notifications.

Signature(Required)

I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid in full, at the time of release of the pet.