Emergency Care Quick In-take Form

Please be patient why we work to assess your pet. A doctor or technician will come speak with you as soon as the pet is stable.

Services that may be performed to stabilize your pet may include: Oxygen Therapy, IV Fluids, IV Catheter, Radiographs, Emergency Office Visit, Pain Medication, In-House Bloodwork, CPCR, ECG Monitoring.

Treatment Authorization: I am the owner or authorized agent for the owner of above-named pet. I have the authority to make medical decisions related to the pet. By signing this Patient Intake Form, I authorize DVH staff to provide care and perform any treatment necessary for the pet. I understand that, with any medical or surgical procedure, there are risks involved, including the risk of death. I acknowledge that no guarantee or assurance is being made as to treatment results.

Acceptance of Financial Responsibility and Deposit: I understand that I must pay a $300 deposit now while the staff is stabilizing my pet for treatment. Once stabilized a DVH staff member will update you and provide an estimate of treatment fees. I acknowledge that an estimate is only an approximation; actual fees may vary. If the pet requires hospitalization, I agree to make another deposit prior to services and pay the balance when the pet is discharged. If I do not pick up my pet at the date and time specified by DVH staff, additional charges will accrue. I recognize that I am responsible for all charges related to the pet, regardless of treatment results. DVH accepts payments in cash, by American Express, Visa, or MasterCard, or through Care Credit. I am aware that all delinquent accounts will be transferred to a collection agency.

I decline, I DO NOT WISH for my pet to receive extensive medical treatment. I wish that my pet only receive the treatment and medications necessary to stabilize and transfer and I realize this may be against medical advice.

Follow up will be made with SAVES and if the animal was not taken you will be reported to the CCAC.