LinkedInThis field is for validation purposes and should be left unchanged.Owner Name*Co-Owner NameAddress* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email AddressHome NumberWork NumberCell Number*Co-Owner Work NumberCo-Owner Cell NumberName of Previous ClinicPhoneMilitary Yes No Senior Yes No Recommended by Whom?*Where did you hear about us?*Reason for Visit* Urgent care Vaccinations General Exam Doctor PreferencePlace of EmploymentFirst PetSelect One:* Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Second PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Third PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Consent to Treat I, the undersigned, certify that I am over the age of 18 and am the owner (or authorized agent) of the above-described patient. I authorize Trout Lake Animal Hospital and Urgent Care (including its affiliates, employees, agents, and contractors) to receive, examine, prescribe for, and treat the above-described pet. I further understand that no guarantee of successful treatment is made, and I will not hold Trout Lake Animal Hospital and Urgent Care (or its affiliates, employees, agents, or contractors) responsible for my pet’s recovery. Payment Policy A deposit may be required prior to treatment and/or hospitalization. Full payment for services rendered is required before your pet is discharged from the hospital. I understand that all diagnostics, treatments, and medication charges are in addition to any examination fee, and I agree to pay all charges incurred at the time of service. Records and Communication Policy Trout Lake Animal Hospital and Urgent Care is committed to your pet’s continuum of care. We may share information regarding your pet’s treatment and/or condition with your family veterinarian, specialists, or a reviewing body when appropriate. By signing below, you authorize Trout Lake Animal Hospital and Urgent Care to share your pet’s medical records with third parties (such as your family veterinarian) or their agents as necessary to ensure continuous veterinary care. You also agree that we (or our agents) may send communications to the contact information you have provided regarding your pet’s care.Signature
EMERGENCIES