Intake - Emergency Pet Clinic of Temecula

Client Information

Name*

First Last

Name of Spouse/Co-owner

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Secondary Phone

Spouse Phone

Email*

Owner Date of Birth*

required for prescription medications

CPR Directive

Additional charges may apply.

CPR Directive*

CPR approved
CPR declined
CPR doctors discretion

Client Initials*

Please initial here.

Patient Information

Pet's Name*

Species*

Canine
Feline
Bird

Breed*

Pet Age/Date of Birth*

Sex*

Male
Female
Neutered Male
Spayed Female

Spayed or Neutered?*

Yes
No

Color

Are you the owner of the pet being treated?*

Yes
No

Reason for Visit*

Current Medication

List any drug allergies

Regular Veterinarian/Veterinary Hospital

How did you hear about us?*

Behavior

Our veterinary hospital takes pride in its compassionate, professional staff, and we expect mutually respectful relationships with our clients. This is an emotionally charged environment for both our clients and our staff. In an effort to protect our employees from verbal abuse and maintain a valid client/patient/doctor relationship any commentary to suggest our primary directive is monetarily based, substandard or allusion to involving an attorney immediately terminates this trust based relationship.

I have read the "Behavior" policy*

Please initial here.

All in-coming and out-going calls are recorded*

Please initial here to acknowledge.

Photo Release

PHOTO RELEASE/CONSENT POLICY
By accessing services or visiting the property associated with Emergency Pet Clinic of Temecula dba “Emergency Pet Intensive Care/EPIC Vets”, you hereby grant permission to use any photographs taken of you or your pet, in any and all of its publications, including social media or website use, without payment or any other consideration. You understand and agree that these materials will become our property and will not be returned. You hereby authorize to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing our programs or for any other lawful purpose. You give authorization to use your name and your pet’s name in any manner.

YOUR PRIVACY IS YOUR RIGHT You have the right to request removal of images at any time from our publications, including social media or website use. To request removal of your content, please email ([email protected]) and include a link or reference to the content you wish to have removed.

I have read the "Photo Release" policy

Please initial here.

Payment in full for all charges are required at time of service.

It is understood that a treatment plan will be presented to me that will include any additional recommended treatments, diagnostics, or procedures and all cost associated with those services. I understand that no guarantee or assurance can be made as to the results that may be obtained. It is thoroughly understood that I assume all risks involved with any treatments or procedures. A deposit of the lower end of the estimated Treatment Plan is required in order to begin treatment of hospitalized patients. Payment in full of the remaining balance must be made when the patient is released. I am 18 years of age and/or over, I understand that I am authorizing care to the animal listed above and responsible for all costs that may be incurred.

We accept cash, Visa, Mastercard, Discover and American Express credit cards, and bank Debit/ATM cards. We also accept Scratchpay and CareCredit financing.

I have read the "Payment" policy*

Please initial here.

Patient Belonging Disclosure for Intake Forms

Emergency Pet Clinic of Temecula will not be responsible for belongings retained with patients at the time of admittance. Your signature for the following disclaimer releases the hospital from any and all liability for the loss or damage to your personal property. I understand that Emergency Pet Clinic of Temecula shall not be liable for loss or damage to personal property. I accept full responsibility for all personal property that is admitted to the hospital with my pet.

I have read the "Patient Disclosure For Intake" policy*

Please initial here.

Owner or Authorized Agent Signature*

I have read the above terms and agree to comply.

Date

Comments

This field is for validation purposes and should be left unchanged.

Open 24hrs.
27727 Jefferson Ave.
Temecula, CA 92590

Intake Check-In

Client Information

CPR Directive

Patient Information

Behavior

Photo Release

Payment in full for all charges are required at time of service.

Patient Belonging Disclosure for Intake Forms

Call Us Today!

951-695-5044