Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare?

First

Last

Phone

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

What is your pet here for today? *

Who is your pet's regular veterinarian? *

Do you have a second pet that needs to be seen today? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a third pet that needs to be seen today? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a fourth pet that needs to be seen today? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a fifth pet that needs to be seen today? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed (copy) *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

How did you find us? If you were referred by someone, who should we thank?

I grant Charleston Veterinary Urgent Care permission to photograph, video, and/or record my pet(s) for promotional, educational, and advertising purposes. I release the clinic from any liability arising from the use of these materials. *

I AUTHORIZE
I DO NOT AUTHORIZE

Payment is due in full at the time that services are performed. We accept cash, debit cards, credit cards (MasterCard, Visa, Discover and American Express) and CareCredit payments. We do not offer payment plans. A deposit may be required prior to a diagnostic work up or medical treatment. A merchant service fee of 3% will be applied to your final invoice if paying with a credit or debit card. *

I have read and accept the financial policy.

I, the undersigned, certify that I am the owner, or an authorized agent for the owner, of the pet(s) listed above, and I have the authority to grant consent. I certify that I am 18 years old or older. I am accepting financial responsibility for this patient's/these patients' medical care. I have read and accept Charleston Veterinary Urgent Care's financial policy. I understand and agree to authorize Charleston Veterinary Urgent Care, their doctors, staff, agents and or representatives to examine, prescribe for and treat my pet(s). I release Charleston Veterinary Urgent Care, their doctors, staff, agents and or representatives from any and all liability. I understand that Charleston Veterinary Urgent Care is not a 24-hour hospital. If hospitalization is recommended, I will be responsible for transporting my pet(s) to a 24-hour emergency hospital for continued monitoring and care. *

I acknowledge that all information I provided in this form is true and accurate.

Signature *

Clear Signature

Date *

Intake and Consent Form

Intake and Consent Form

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