Client Information Form

Employer:*

Additional Contact & Relation; If pet owner is unavailable:*

Name:
Phone Number:

Have you ever been here before?*

Yes

Has this pet been here before?*

Yes

Patient Name*

Type of Animal*

Breed*

Date of Birth*

Sex*

Male

Male Neutered

Female

Female Spayed

Unknown

Diet*

Diet or brand fed:
How often fed:
When last ate:

Primary Veterinarian/Hospital/Clinic*

Please describe the current problem for which your pet is here*

Please check any symptoms or problems that you have noticed about your pet:*

If you have any previous medical records or X-rays for your pet, please email them to us at alliedvet.office@gmail.com.

Will you be sending any documents our way?*

Yes

Code Status*

CPR

DNR

Current medications (including heartworm prevention, flea control, special diet, etc.)*

Monthly Heartworm/Flea Medication*

Rabies Vaccinated*

Yes

Any known allergies or drug sensitivities? If yes, please describe*

How did you hear about us?*

My Vet

Yellow Pages

Internet

Hospital Sign

Other

Will you allow images of your pet on our website/social media?*

Yes

Our doctors use AI software to complete their medical records, so your visit today will be audio recorded. Do you consent to audio recording to aid in patient medical record?*

Yes

Client Expectations:

To ensure that every pet receives the care they need, all emergency cases are seen based on a Triage System, which prioritizes the most critically ill patients.

Critical patients, such as those with severe trauma, breathing difficulties, or a loss of consciousness, are seen immediately.

Stable patients, while still in need of urgent attention, will experience variable wait times, which can range from 1 to 6 hours or longer. The length of your wait depends on the number and severity of other emergencies we are managing at any given moment.

Our team is working as quickly as possible, and we appreciate your patience and understanding. We will provide updates throughout your visit and will make your pet's comfort and care our priority. If you have questions or concerns, please do not hesitate to ask our front-desk team.

We have a zero tolerance policy for abusive and violent behavior toward our staff. We expect all clients and their family members to treat our staff with courtesy and respect.

As we care for your pets, please care for our staff. Serious psychological stress and burnout are on the rise in veterinary professionals across the country. Help us provide support to end this silent epidemic by treating our staff with kindness and respect. We want the best for you and your pet, so let’s work together to make that happen. Thank you for your understanding and support.

Personal belongings, please take all belongings with you. We are not responsible for lost or damaged personal property that is left behind. Any belongings left behind are subject to immediate disposal at the time of discharge.

Prescription refills, we require an updated physical examination prior to authorizing any prescription refills. Refills may be considered at a later date under specific circumstances, but are not entitled to be refilled upon request. Clients are advised to contact their primary care veterinarian to provide an update on their pet’s condition, schedule follow-up care, and coordinate ongoing prescription refills through their office.

Notification Regarding Abandoned Animals, This notice serves to inform you that failure to retrieve your pet or maintain communication with our facility regarding your pet’s care may constitute animal abandonment under Florida law.

Florida Statute § 828.13 defines abandoning an animal as forsaking it or failing to provide necessary care and support. Prohibited actions under this statute include, but are not limited to: Abandoning a sick or injured animal, leaving a pet without written formal approval for treatment, care, and payment provided prior to leaving the facility. A violation of this statute is classified as a first-degree misdemeanor, punishable by a fine of up to $5,000, imprisonment for up to 365 days, or both. If you fail to communicate with our team or do not pick up your pet by the specified deadline, we may be required to proceed in accordance with applicable state regulations regarding abandoned animals. Our facility will make all reasonable attempts to contact you before taking further action. After 3 days, a formal letter will be mailed; after 10 days our facility will contact Animal Control and arrange transfer to their care.

By providing authorization below, you acknowledge acceptance of this statement and agree to adhere to the outlined policies. Failure to comply may result in removal from the facility and termination of current and future professional services.

WE DO NOT ACCEPT CHECKS
Read the following carefully and sign: Answer all of the fields below completely. Payment is required when the service is rendered. A deposit is required for all hospitalized animals & surgical procedures.

Method of Payment*

Cash

Care Credit/Scratch Pay

Debit/Credit

Trupanion

I hereby authorize Allied Veterinary Emergency Hospital, its representatives, agents, or employees to perform the surgery and/or other necessary services on the above-described animal. I further certify that I have ordered, or have been authorized by the owner to order, the named services for the above-described animal. In any event, I accept full financial responsibility for the payment of services ordered and rendered.

I understand that any animal not called for within 3 days of the date that the hospital shall designate for its release shall be considered abandoned by me, and shall be disposed of at the discretion of the hospital. My financial responsibility shall not in any way be altered by such disposal, and my indebtedness shall include all charges made against such animal up to and including the date of, and charges for, disposal of the same. Should it become necessary to collect this account through an attorney, the undersigned agrees to pay all costs of collection, including reasonable attorney’s fees.

Authorization*

Owner/Agent Signature:
Date:

Client Information Form

Employer:*

Additional Contact & Relation; If pet owner is unavailable:*

Have you ever been here before?*

Has this pet been here before?*

Patient Name*

Type of Animal*

Breed*

Date of Birth*

Sex*

Diet*

Primary Veterinarian/Hospital/Clinic*

Please describe the current problem for which your pet is here*

Please check any symptoms or problems that you have noticed about your pet:*

If you have any previous medical records or X-rays for your pet, please email them to us at alliedvet.office@gmail.com. Will you be sending any documents our way?*

Code Status*

Current medications (including heartworm prevention, flea control, special diet, etc.)*

Monthly Heartworm/Flea Medication*

Rabies Vaccinated*

Any known allergies or drug sensitivities? If yes, please describe*

How did you hear about us?*

Will you allow images of your pet on our website/social media?*

Our doctors use AI software to complete their medical records, so your visit today will be audio recorded. Do you consent to audio recording to aid in patient medical record?*

Method of Payment*

Authorization*

If you have any previous medical records or X-rays for your pet, please email them to us at alliedvet.office@gmail.com.

Will you be sending any documents our way?*