Check-in Form

Name: Rockwall Urgent Vet
Address: 3084 N. Goliad St. Suite 104, Rockwall, TX, 75087, United States
Telephone: 469-769-7222
Price range: $

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Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Drivers License State *

Drivers License Number *

Pet Name *

Pet Age (years) *

Species *

Sex *

Male
Neutered Male
Female
Spayed Female

Breed *

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
Facebook
Drive By
Vet Clinic
Other

If other, please explain. *

Who may we thank? *

If your pet is stable & being seen for an urgent but non-life-threatening illness, an estimate for diagnostic & treatment will be provided after the physical exam ($125).

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. I understand that I am approving $600-800 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.

Client Signature *

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