CLIENT INFORMATION

Owner or Guardian's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email Address *

Home No

Work

Cell

Secondary Contact

First

Last

Secondary Cell No

Secondary Email

PATIENT INFORMATION

Pet's Name *

Species *

Dog
Cat
Other

Breed *

Colour *

Age/DOB *

Sex *

Male
Male (Neutered)
Female
Female (Spayed)

Regular Veterinary Clinic *

Reason For Visit (Check all that apply) *

If Other, please explain

When did this issue begin? *

Has it been: *

Getting better
Getting worse
Staying the same

Has your pet had this issue before? *

Yes
No

If yes, when and what treatment was given?

Is your pet currently on any medication? *

Yes
No

If yes, please list

Any known allergies or past medical conditions? *

Up to date on Vaccines? *

BEHAVIOR AND GENERAL HEALTH

Eating normally? *

Yes
No

Drinking normally? *

Yes
No

Urinating/defecating normally? *

Yes
No

Any recent changes in behavior or routine? *

I authorize my animal to be examined on this date by the attending veterinarian at Eagleson Veterinary Clinic. I fully understand that the fee for examination and consultation is $260.00 plus HST. Additional services may be warranted and will be discussed with the veterinarian. An estimate will be provided prior to any treatments being given, except when urgent medical treatments are required. Payment for all treatments or medications is due at the time they are provided. If an animal is admitted to the hospital, a 100% deposit of the estimated cost is required at the time of admission. The remaining balance, if any, is due at discharge or transfer. Any unused portion of the deposit will be refunded at discharge. We accept Visa, MasterCard, debit, and cash. Please note that we do not accept cheques and do not offer payment plans.

Triage Fee/Deposit

I understand that I will be asked to leave a $45.00 deposit after my pet has been triaged. I understand that this fee will be applied to the final invoice as a payment, or applied as a triage fee should I decide not to wait to see a DVM.

Social Media

Here at Eagleson Veterinary Clinic, we love to share stories of furry family members that visit our hospital. Let us know if you want us to share pictures or stories of your pet on our social media pages. These posts are to help provide education and information to others.

I consent to picture(s) and information about my pet being shared on social media (While we make our best effort to share stories, we may not be able to feature every pet.)
I do not consent to picture(s) and information about my pet being shared on social media.

Privacy

Eagleson Veterinary Clinic takes your privacy seriously. Any personal information we collect is stored securely and is only used or disclosed for the purposes under which it was collected. Your information may only be shared with third parties when necessary for providing medical treatment or client communications, or at your request.

By signing below, I consent to the use, storage, and disclosure of my information for the purposes of providing medical treatment to my pet and communicating with me, my regular veterinarian, or my pet insurance provider about these treatments. *

Initial

Please select ONE of the directives listed below:

Resuscitate (R): I authorize emergency treatment if the situation arises (including cardiopulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges and I agree to pay for these emergency and life-stabilizing treatments even if the cost exceeds any estimate I may have been provided.
Do Not Resuscitate (DNR): I do NOT authorize emergency treatment if the situation arises (including cardiopulmonary resuscitation (CPR) and other life-saving treatments) and prefer to be contacted before any additional treatment is performed.

I confirm that I am 18 years of age or older and legally authorized to make medical decisions for the pet mentioned above. If I am under 18, I understand that a parent or legal guardian must be present to provide consent for any treatment.

Emergency

In the event my pet experiences a cardiac, respiratory, or other life-threatening emergency that requires resuscitative or other urgent care measures, such as cardiopulmonary resuscitation (CPR), positive pressure ventilation, emergency drugs, or other similar measures, I request that the veterinarians and/or trained staff at Eagleson Veterinary Clinic pursue such medical care as indicated below.

Signature *

Clear Signature

Print Name *

Date *

Request An Appointment

Emergency

Triage Intake Form