Pet + ER Registration Form

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Exam Consent Form

Pet + ER currently requires mobile check-in for all Emergency Services. Completion of these forms helps us and enables us to:

Prioritize evaluation of pets based on the urgency of need.

Gain approval for initial diagnostics.

Expedite examination and treatments.

Though we cannot take the wait away, it allows our valued clients and patients the ability complete their check in and monitor their spot in line from the comfort of their own homes during periods of potential extended wait times.

Please complete all questions that apply to your pet's visit today. Once completed you will receive a text message that confirms your spot in line to be seen at the Pet + ER in Columbia.

Before we start, please close other apps (streaming media, social media, maps) to get the best experience.
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Pet's Name & Owner's LAST Name* This field is required.
Pet's Name
Owner's LAST Name
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Is your pet experiencing one of the following? Severe trauma (example, hit by car, fall from a high place) Active seizures/multiple seizures (in the past 24 hours) Heatstroke or severe fever Gasping for breath or obstructed airway Open mouth breathing/panting (cats) Coma/collapse/unresponsive Life-threatening injury Uncontrolled bleeding Exposed bone or internal organs Pale, white or blue gum color
YESNO
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Your pet MAY be in critical condition, please call us at (410) 441-3304 so we can get more information. You may complete this form after you speak with one of our staff.
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What is the reason for your visit today?* This field is required.
Emergency/Urgent Care
After care services
Referred from primary veterinarian
Bringing in a stray
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Please select your visit reason:* This field is required.
After care services/Pet passed away at home
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We understand that the relationship you and your family shared with your pet is special and unique. Pet + ER would like to make the difficult process of saying goodbye to your beloved pet as comfortable as possible. At this time, we will be asking a few questions so we may begin to preprare for your arrival.
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ErxConfirmationNumber* This field is required.
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Owner's Full Name* This field is required.
First Name
Last Name
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Primary Phone Number* This field is required.
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Email Address
example@example.com
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Secondary Contact Name:
First Name
Last Name
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Secondary Contact Relation (to you):
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Secondary Contact Phone number:
Phone number
Please Select
Please Select
Cell
Home
Work
Type
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Is this person able to authorize care if you are unreachable?(Note: If yes, primary owner will be responsible for the charges authorized)
YESNO
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Pet Information* This field is required.
Pet's Age:
Please Select
Please Select
Cat
Dog
Other
Species
Breed
Color
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Date* This field is required.
Date
Year
Month
Day
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Please call us at (410) 441-3304 so we can get more information and confirm we are able to see your pet today. You may complete this form after you speak with one of our staff.
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Pet's Sex* This field is required.
Male, Intact
Male, Neutered
Female, Intact
Female, Spayed
Unknown
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Does your pet require special handling or accommodation (ie, muzzle, sedation for visits, cage, and/or animal aggression)?
YESNO
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Please specify:
Huge
Large
Normal
Small
Ok
Ok
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Who is your primary veterinary clinic?* This field is required.Please type the name of the clinic/hospital and the city it is located in.
Name of clinic and city
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What is the name of your pets primary care veterinarian(DVM)?
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Has your pet ever been a patient at the Pet + ER Columbia before?* This field is required.
YESNO
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If yes please provide the reason for visit and approximate date.
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Ok
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Is your pet a current patient at CVSS (Chesapeake Veterinary Surgical Services), CVCA (Chesapeake Veterianary Cardiology Association), VNIOC (Veterianary Neurolgy and Imaging of the Chesapeake) or AVIM&O (Atlantic Veterianary Internal medicine and Oncology) at this location or another location?
YESNO
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Please list the condition requiring specialist care and last appointment date.
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In as much detail as is necessary, please describe the reason for today's visit, including symptoms (i.e., lethargy, vomiting, exposure to toxin injury or wound, not eating, etc.) and how long these symptoms have been present.* This field is required.
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Has any treatment been provided for this listed event, including at-home or with another veterinary hospital?
YESNO
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Has any treatment been provided for this listed event, including at-home or with another veterinary hospital?
YESNO
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What has that included?
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Does your pet have any chronic conditions or are they under treatment by any other veterinary professional for any medical problem?* This field is required.
YESNO
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List conditions:
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Ok
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In the past month has your pet been in close contact with other animals outside the home (dog park, groomers, boarding facility)* This field is required.
YESNO
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If safely possible, and applicable to the situation you may provide a photo for our veterinary staff to view. (Ex. a wound, injury, foreign material in stool etc.)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Please describe in your own words what seems to be the problem, where it is located, and the duration of symptoms:* This field is required.If not applicable, leave blank.
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Ok
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Does your pet have any allergies to medications or foods?* This field is required.
YESNO
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Describe allergies:* This field is required.
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Is your pet up to date on the following vaccines? Canine rabies, parvo, distemper, lepto, lyme and influenza vaccinations* This field is required.
YESNO/NOT SURE
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Is your pet up to date on the following vaccines? Feline rabies & feline distemper (FVRCP)?* This field is required.
YESNO/NOT SURE
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Is your pet on any of the following monthly preventative medications?* This field is required.
Long-term heartworm prevention.
Intestinal parasite prevention
Flea prevention
Tick prevention
None of the above
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Are you currently giving your pet any other medications or supplements? (This is to include all current, medications given within the last 48-72 hr.* This field is required.
YESNO
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Please list the name, dose, frequency, and time/date the medication was last given.* This field is required.
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I authorize administration of pain medications as necessary to provide comfort and to proceed with necessary treatments (estimated costs $80-$150). * This field is required.
AuthorizeDecline
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CPR/DNR Order* This field is required.Should your pet experience a cardiac or respiratory event that causes their heart to stop or they stop breathing, would you want us to try to resuscitate your pet?
Basic CPR (Cardiopulmonary Resuscitation) - I DO wish the staff to perform on my pet if my pet suffers from cardiac or respiratory arrest. Medical resuscitative efforts include airway support, ventilation, thoracic compressions, and drug therapy if indicated. Additional cost = $250 - $800
DNR (Do Not Resuscitate) - You do not have my permission to provide life saving treatment or CPR without checking with me first.
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We are a 24/7 facility and as such we will around the clock continue inviting clients and their pets to our hospital when it is their turn to be seen by a veterinarian. We also want to be respectful of our clients that do not wish to receive late-night phone calls (calls that are between the hours of 10 pm and 6 am). Below is your opportunity to either accept calls around the clock when it is your turn in line or opt-out of overnight calls. (Please note that opting out may result in an overall increased wait time.)
Accept calls any time
No calls between 10pm and 6am
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Do you have Trupanion Pet Insurance?
YESNO
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Please provide your Trupanion policy number.
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Photo/Story Consent

Pet + ER would like permission to use your pets photo for the following: Website, Facebook, artwork media or publication.

I hereby grant permission to Pet + ER to use my pet’s medical story, my own image and my pet’s image in perpetuity, in any media or publications, now known or hereinafter devised, and I acknowledge the right to alter said image(s) at their discretion. I also acknowledge that they may choose not to use these images or my pet’s medical story at this time but may do so at their discretion at a later date. Pet + ER also reserves the right to discontinue use of said images without notice. I understand that if my own image or my pet’s image is used, published, or posted on the Pet + ER websites or social media sites for Pet + ER, the image is available to be downloaded by any computer user. Therefore, I agree to indemnify and hold Pet + ER harmless from any claims arising from use of said images.

Consent Granted Consent Denied *
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Authorization Signature - I hereby agree to the above terms and conditions and authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for the $190 emergency exam fee and any additional charges incurred for the care of this animal. I also understand that any outstanding fees will be collected at the time of my pet’s discharge and that a deposit may be required for extended emergency treatment.* This field is required.
Clear
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It is Pet + ER in partnership with Agape Pet Service’s privilege to be entrusted with carrying out your wishes when it comes to the final disposition of your pet’s remains. We wish for you to have all the information you need, and to provide you the opportunity to begin thinking about what these wishes are for your companion. As such we have provided a list of all services provided along with pricing, so you may take the time you need for such a decision. (Please note: prices are for aftercare services only)

Aftercare options are:

Private Cremation: Your pet's remains are returned to you.

Communal Cremation: Your pet's remains are not returned to you.

Hold - Pet + ER will hold your pet for 7 days.
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Your name* This field is required.
First Name
Last Name
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Where was the pet found?* This field is required.
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Please upload a picture of the FRONT of your driver's license. * This field is required.
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Select files to upload
Max. file size: 10.6MB
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Please upload a picture of the BACK of your driver license.* This field is required.
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Select files to upload
Max. file size: 10.6MB
Cancelof
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By signing below, I understand that once Pet+ER takes responsibility for a lost or stray animal that they can no long disclose any information about the animal's care, location or status. Animals in need of immediate medical care will be treated at the discretion of the licensed Doctor of Veterinary Medicine on shift at the time of drop off. All animals per state law will be picked up by animal services of the county in which it was found at their earliest possible convenience. Should I wish to potentially adopt or foster the animal I understand that I need reach out to the appropriate county animal services for those inquiries.* This field is required.
Clear
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