Marketing Archives | Animal Emergency And Surgery Center

405-631-7828

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Exam Fee $150 (does not cover diagnostics or treatment). Payment due prior to service.

CLIENT INFO

Name *

First

Last

Secondary Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

I consent to receive SMS text messages from Animal Emergency and Surgical Center. Msg & data rates may apply. Reply STOP to opt-out. *

Secondary Phone

Email *

PATIENT INFO

Name *

First

Last

Species *

Canine
Feline

Age/DOB *

Breed *

Color *

Weight *

Is your pet female or male? *

Female
Male

Is your pet spayed or neutered? *

Referring Veterinarian *

Reason for Visit *

CONSENT FOR EXAMINATION

This form acknowledges that I have authorized Animal Emergency & Surgical Center (AEC) to examine my pet. I am aware that all expenses incurred during the diagnosis and treatment of my pet are required to be paid in full at the initiation of care with the Animal Emergency & Surgical Center. If I decline treatment of said animal, I will not hold Animal Emergency & Surgical Center or its staff response. The signature acknowledges your consent for the emergency exam fee of $150.00. If AEC feels that your pet is too aggressive for a regular examination and requires sedation, this consent will apply to charges for any sedation that is used during the examination. *

I have read and understand

AUTHORIZATION FOR CPR

Fees for CPR start at $600.00 and can increase based on the number of injections given and the weight of the patient. You can change this at any time, but YOU MUST LET AEC staff know so it can be changed. Animal Emergency & Surgical Center may recommend your pet be hospitalized; in the event your pet(s) condition declines, AEC would like to know in advance the wishes of the family. *

I have read and understand

Do you want CPR for your pet? *

Signature *

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Date *

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Exam Fee $150 (does not cover diagnostics or treatment). Payment due prior to service.

CLIENT INFO

PATIENT INFO

CONSENT FOR EXAMINATION

AUTHORIZATION FOR CPR

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