Emergency Exam Form

Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. We will need to be able to contact you or someone with permission to make medical and financial decisions.

Name(Required)

First Last

Phone(Required)

Email(Required)

Pet's Name(Required)

Pet's Age

Pet's Breed

Who should we contact to make medical decisions today?

Owner (Named Above)

Someone Else (Named Below)

If you have any questions, please contact our team members prior to your arrival for assistance.(Required)

I have read and understand.

Reason for visit: (check all that apply)

Illness

Injury

Other

What symptoms has your pet been experiencing?

Are there any concerns for the following: (check all that apply)

Increase in appetite

Decrease in appetite

Increase in drinking

Decrease in drinking

Attacked by another dog or cat

Attacked by a wild animal

Bitten by a snake or insect

Stung by a bee

Facial swelling

Hives

Fallen down stairs

Hit by car

Excessive Sleeping

Seizures

Vomiting

Diarrhea

Itching/Scratching

Shaking Head

Bad Breath

Weight Loss

Weight Gain

Urination Issues

Excessive Sleeping

Scooting

Difficulty Rising

Skin Masses (explain below)

Car Sickness

Behavioral Problem

Toxicity, has your pet ingested anything abnormal (explain below)

Other (explain below)

When did the problem start?

Have the symptoms worsened, improved, or stayed the same since you first noticed them?

No change

Worsened

Improved

Does your pet have a history of seizures?

Yes

If Yes, please specify

Has your pet experienced this problem in the past?

Yes

If Yes, please specify

Is your pet on any medications?

This includes heartworm/flea prevention, over the counter and prescription

Yes

If Yes, please specify

Has your pet had any surgeries in the past?

Yes

If Yes, please specify

What brand of food do you feed your pet?

How much do you feed?

Free fed (food is offered always/whenever hungry)

Measured amount (specify how much and how often below)

Specified Amount

Have there been any changes in appetite?

Increased

Decreased

No change

If there has, for how long? Please elaborate.

Any increase or decrease in water consumption?

Increased

Decreased

No change

Any change in bowel movements?

Yes

Unsure

If Yes, please specify

Does your pet spend time outside, even for walks or in the yard?

Yes

Does your pet come into contact with other dogs?

Please check all that apply

Boarding

Grooming

Dog Parks

Other

None of the above

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?

Yes

If Yes, please specify

Is your pet current on vaccines?

Yes

Unsure

If Yes, please specify which vaccine and expiration date

Do you have a copy of your pets most recent Rabies certificate?

If Yes, please specify the clinics name and email certificate to Hospital@truecompanionvetcare.com

Yes

Do you have a regular veterinarian that your pet sees?

Yes

Unsure

If Yes, please specify the clinic’s name

CPR Permission(Required)

I understand True Companion Veterinary Care, PLLC (TCVC) requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. I acknowledge that the attending veterinarian or staff members of TCVC, PLLC will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $400. I understand that there is no guarantee of successful resuscitation.

Yes, please perform CPR on my pet.

No, do not perform CPR on my pet.

Once you arrive for the emergency, we require the $120.00 exam fee to be collected upfront.(Required)

I have read and understand

Financial Responsability(Required)

Once the doctor has completed your pet’s exam, we will contact you to go over the recommended treatment plan. I understand that financial responsibilities for services are rendered when the treatment plan is approved..

I have read and understand

Emergency Procedures(Required)

By agreeing to such emergency procedure, I am aware that I will be held responsible for all services provided to my pet. I also understand that despite the best effort of the doctor and staff at this facility, even the most successful CPR that may restore my pet's life, may not allow my pet to regain normal mental or physical health.

I have read and understand

PAYMENT:(Required)

Payment in full is required at the end of your visit today. Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations. We accept Visa, Mastercard, American Express, Discover, CareCredit and Scratchpay for payment. Should you opt for CareCredit or Scratchpay as your form of payment, we ask that you apply prior to your visit to streamline your appointment. We do not accept checks and strongly discourage the use of cash due to the global pandemic.

I understand.

Social Media/Photo Permission

Do we have your permission to post photos of your pet online? Your pets' picture or video may be taken while they are with us and used for True Companion Veterinary Care advertisement (www.truecompanionvetcare.com) or other social media purposes (Facebook, SnapChat, Instagram, etc.). Please indicate if you authorize for their pictures/videos to be posted or used. * If you do not authorize for your pet’s picture to be included in our marketing materials/venues, we may still use a picture of your pet in our patient records for our internal identification only*

Yes

I give True Companion Veterinary Care authorization to treat as discussed above.(Required)

I have read and agree.

If Curbside care is elected:(Required)

If Curbside care is elected: During the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from outside the building and support them through the exam, any services required, and then bring them back to your vehicle, when your pet is ready to go home. We strongly recommend you head home and a veterinarian or nurse will call you to discuss your pet’s exam and discuss recommended treatments, preventative measures and give an estimated discharge time.

I have read and understand.

PHOTO ID REQUIRED FOR PAYMENTS(Required)

Photo ID required for all credit card, debit card, Care Credit and Scratchpay transactions. The photo ID must match the name on the card. All credit card, debit card, Care Credit and Scratchpay holders must be physically present to run the card and sign the transaction in person.

I have read and understand.

Please type your initials.(Required)

Date

MM slash DD slash YYYY

Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days?

Yes

Have you or anyone in your house experienced the following symptoms in the past 14 days?

Cough

Shortness of breath

Fever

Sore throat

Chills

Muscle pain

Headache

New loss of taste or smell

Who experienced these symptoms?

Self

Someone else in the house

No symptoms

If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment

Cancellation Policy:(Required)

I understand that appointment cancellations less than 24 hours before appointment and/or no shows will incur a $65.00 cancellation fee.

Please type your initials.(Required)

Date

MM slash DD slash YYYY

Signature

Comments

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

832-930-7717

If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment