YOUR NAME* First Last ADDRESS* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Number*PLEASE PROVIDE THE NUMBER FOR THE PRIMARY CONTACT/DECISION MAKER THAT WILL BE PRESENT FOR YOUR PET'S VISIT. EMAIL ADDRESS* DRIVERS LICENSE STATE*TexasTexasAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDRIVERS LICENSE NUMBER*PET NAME*PET AGE (years)*Species*DogCatPET SEX*MaleNeutered MaleFemaleSpayed FemalePET BREED*PET COLOR*Who is your primary care Veterinarian (& Hospital Name)?*What is your primary concern today? (Reason for visit)*How did you hear about us?Google SearchFacebookDrive ByVet ClinicRockwallianOtherWho may we thank?Vehicle Make, Model & Color*Let us know what vehicle to expect!CRITICAL CARE CONSENTThis will only apply if your pet is deemed to be critically ill or actively dying. If your pet is deemed to be in critical condition at triage, life saving measures will only be provided with your consent. Please indicate your wishes below:*I authorize immediate care for my pet if needed. I understand that I am approving $800-1200 for initiation of life saving treatments.I do not wish for life saving measures to be performed. I understand that this may result in the death of my pet.***PLEASE READ CAREFULLY BEFORE SIGNING THIS FORM***(1.) A WAITLIST TIME IS NOT AN APPOINTMENT. (2.) WAIT TIMES ARE GENERALLY 1-2 HOURS OR LONGER. (3.) WE ARE ONLY PROVIDING CONTACTLESS SERVICES. (4.) YOU MUST REMAIN ON PREMISES UNTIL YOU SPEAK TO THE VETERINARIAN. (5.) YOU MUST ANSWER YOUR PHONE PROMPTLY. (6.) PAYMENT IS DUE AT TIME OF YOUR VISIT. WE DO NOT OFFER PAYMENT PLANS. (7.) YOU MUST CALL US WHEN YOU ARRIVE. WE DO NOT MONITOR THE PARKING LOT. By signing this form, you understand that failure to adhere to our policies will result in losing your place on the waitlist and we may not be able to see your pet.I UNDERSTAND THAT CONTACTLESS SERVICE IS ONLY PROVIDED AT THIS TIME. COMBATIVE DISCUSSION WILL NOT BE TOLERATED AND I WILL BE ASKED TO LEAVE IF THIS OCCURS.*YES, I UNDERSTAND.If you do not agree with this statement, we will be unable to see your pet today. I UNDERSTAND THAT A WAITLIST TIME IS NOT AN APPOINTMENT. WAIT TIMES ARE STILL EXPECTED. I understand that this is largely dependent on staffing, hospitalized cases and critical cases that arrive. Furthermore, I have been informed that patients in a critical state will be seen first.*YES, I UNDERSTAND.Second ChoiceThird ChoiceIf wait times are not acceptable to you, we will not be able to see your pet. Please be patient with our staff. We expect mutual respect, understanding and transparent communication in order to provide the best possible care for your pet. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALERTING STAFF WHEN I HAVE ARRIVED. THE PARKING LOT IS NOT MONITORED. WAIT TIMES WILL OBVIOUSLY BE EXTENDED OR I MAY EVEN LOSE MY WAITLIST TIME IF I DO NOT CALL WHEN I ARRIVE.*YES, I UNDERSTAND.Second ChoiceThird ChoiceClient Signature*Your electronic signature makes this a legally binding document. NameThis field is for validation purposes and should be left unchanged.
