Pet Details

Pet Name(Required)

Name

Breed(Required)

Species(Required)

Sex(Required)

Male

Female

Male Neutered

Female Spayed

Weight

Date of your pet's appointment(Required)

Owner Details

Name(Required)

First Last

Email(Required)

Please list ALL numbers where you can be reached today:(Required)

May we text you if we cannot reach you by phone? *(Required)

Yes

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please Iist any concerns you have about your pet) and the approximate date/time of onset:(Required)

After the veterinarian has examined your pet you will receive a phone call with a treatment plan and recommendation that includes an estimate of cost. In the event that we are unable to contact you, Please list your preference:

I consent to any recommended testing or treatment up to $:(Required)

EMERGENCY AUTHORIZATION

In the extremely rare event that life-saving treatments are required, we need to know your preference:(Required)

Records of your pet’s visit will be sent to your pet’s regular veterinary clinic (if not NSVC). Please provide the clinic name here:(Required)

PATIENT MEDICAL HISTORY

Please list all medications or supplements your pet is taking - include 1) Name of item 2) Dosage 3) Time last given(Required)

Any known reactions or allergies to medications or vaccinations?(Required)

Yes

If yes, Please describe:

At what time did you pet last eat a meal?(Required)

Has your pet shown recent signs of illness such as vomiting, diarrhea, coughing or sneezing?(Required)

Yes

If yes, Please describe:

Has your pet shown changes in appetite, drinking or exercise habits?(Required)

Yes

If yes, please describe:

Please list any belongings left with your pet (The clinic will not be resoponsible for lost items.):(Required)

Please list any behavioral or handling concerns (fear biting, dog aggression, pain, etc.):(Required)

MEDICATION PREFERENCES

Select One(Required)

I prefer giving oral tablet medications if possible.

I prefer giving oral liquid medications if possible.

I am unable to give any oral medications and prefer you give my pet injection medications when possible.

The information provided on this form is true to the best of my knowledge. I authorize North Seattle Veterinary Clinic to examine and initiate for my pet. This may include treatment for shock and pain. I understand that no guarantee or warranty for success can be given and that some risks are involved in all procedures and treatments. I assume financial responsibility for charges incurred to this patient. if I am not the owner of the animal, I represent that I have been given authority by the owner to obtain medical treatment for this patient, and to incur costs of its care. I understand payment in full is due at the time that I pickup up the patient.

Client Signature(Required)

Date

Name

This field is for validation purposes and should be left unchanged.

Urgent Care
Consent Form

Pet Details

Owner Details

EMERGENCY AUTHORIZATION

PATIENT MEDICAL HISTORY

MEDICATION PREFERENCES

Why Choose Us

Request a Refill

Schedule a Visit

Get in Touch

Urgent Care Consent Form

Pet Details

Owner Details

EMERGENCY AUTHORIZATION

PATIENT MEDICAL HISTORY

MEDICATION PREFERENCES

Urgent Care
Consent Form