Previous Medical Request / Release

Owner and Pet Information

Name

First

Last

Email

Phone

Pet Name

Veterinarian Information

(Your pet’s regular attending veterinarian)

Veterinarian’s Name:

Hospital / Clinic’s Name:

Hospital / Clinic’s Phone Number:

Hospital / Clinic’s Address:

City

State

Zip

Emergency Medical Attention

Please read and initial below which option you would prefer should it become necessary to seek medical attention for your pet during their stay.

In case of a routine medical problem, I would like my pet to be taken to my regular attending veterinarian as listed above for follow up care. By choosing this agreement, I understand that I am responsible for all charges incurred and that I must have a valid credit card number on file. Should my veterinarian be unable to see my pet or my emergency contact unable to transport my pet to my regular veterinarian, I understand that my pet will be transferred to the adjoining veterinary hospital, Veterinary Care Center of Richmond for all pertinent treatments.

In case of an evening emergency, I would like my pet to be taken to an emergency facility for follow up care. By choosing this option, I understand that I am responsible for all charges incurred and that I must have a valid credit card number on file.

In case of the need for medical treatment, I would like my pet to be taken to Veterinary Care Center of Richmond for follow up care. By choosing this option I understand that I am responsible for all charges incurred and that I must have a valid credit card number on file.

Vaccination & Health Information

Written proof of vaccinations within the last eleven months must be submitted. Please indicate below which vaccinations have been administered to the guest.

DHLPP

Yes

No

Date

Bordetella

Yes

No

Date

Lepto

Yes

No

Date

Lyme

Yes

No

Date

Rabies

Yes

No

Date

FVRCP

Yes

No

Date

FELV

Yes

No

Date

Fecal

Yes

No

Date

Influenza

Yes

No

Date

Heartworm / Flea & Tick Preventative Applied

Yes

No

Date

Acknowledgement

All guests will be checked for fleas and ticks upon arrival. If any fleas or ticks are found the guest will be treated with Capstar and/or Frontline prior to entering the main facility at the owner’s expense. This is for their protection, and for the protection of our guests as well

I understand

Signature

Clear

Date

Previous Medical Request / Release

Owner and Pet Information

Veterinarian Information

Emergency Medical Attention

Vaccination & Health Information

Acknowledgement

Contact Info

Highlighted Partners

Emergency Partners

Patient Forms