New Patients — Island Pet Urgent Care

Pre-Registration

Please complete the form below. All fields marked with a * are required.

Name

First Name

Last Name

Phone Number with Area Code

Phone Type

Additional Phone Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Your Pet's Regular Veterinarian

Your Pet's Regular Veterinary Clinic

Pet's Name

Your Pet's Info

Species, Breed, Sex, Color

Spayed/Neutered?

If unknown, please check no.

Yes

Date of Birth

OR estimated age:

YYYY

Do you have pet insurance?

Yes

If yes, what company?

Reason for Visit

Social Media Consent

By clicking yes, you give permission for Island Pet Urgent Care to post images of your pet on our social channels.

Yes

Authorization

I, the undersigned, am the owner or agent for the owner of the animal(s) described, and I have the full and exclusive authority to execute this consent. - I certify that I am 18 years of age or older. - I give permission to doctors, staff, authorized agents, or representatives of this hospital to examine, prescribe for, and treat my pets. - I agree to pay for all services rendered and medications, goods, and supplies when purchased. - I understand that all fees are due at the time services are rendered and the hospital accepts cash, check, and all major credit cards. - I understand that a deposit may be required for surgical or medical treatment. - I understand that if my pet requires hospitalization, they must be transferred to a 24/hour referral hospital for continued monitoring and care. - I release this hospital from any and all liabilities. - I understand that a merchant service fee of 2.98% will be applied to any final invoice if paying with a credit card. By my signature below, I hereby acknowledge that I agree to all of the above and acknowledge the receipt of a copy of this agreement upon request.

Pre-Registration

ISLAND PET URGENT CARE