Alpenglow Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Client Information Your Name(s): * Street Address: * City: * State: * Colorado Alabama Alaska Arizona Arkansas California Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: * Best Phone: * Home Phone Work Phone: Cell Phone: Email Adress: Have you been here before? YesNo Authorized Party (if other than owner): Reason for Visit? Referring Veterinarian Referring Clinic Who is your pet's regular veterinarian? Do you qualify for a senior citizen discount (65 years or older) YesNo Pet Information Pet's Name: * Species: * Canine Feline Pocket Pet Breed: Color Age: Birthday (if known): Sex: * Male Female Altered: * Neutered/Spayed Intact Initial Presenting Problem: Known Allergies?: Chronic Health Conditions? (please describe) Is your pet on any medications (please list all and their doses)? Additional Pet Information CPR/DNR Code * Yes, Please Administer CPR No, Do Not Resuscitate (DNR) CPR (Cardiopulmonary Resuscitation)/DNR (Do Not Resuscitate) To allow for optimal treatment of your pet(s), all patients hospitalized at Alpenglow Veterinary Specialty + Emergency Center are assigned a CPR code. This code enables AVSEC to carry out your wishes if it becomes necessary during or following an emergency. Key Messages: CPR is used to attempt to restore heart rhythm and breathing. A DNR tells the veterinary care team not to give CPR if your pet’s heart and/or breathing stop. About CPR CPR (cardiopulmonary resuscitation) is a combination of chest compressions and rescue breathing given to a pet whose heart has stopped beating and/or has stopped breathing. CPR may include the following: - Manual chest compressions (performed using the hands) - Defibrillation (a brief electric shock applied to the chest to restore a normal heart rhythm) - The use of drugs to stimulate the heart - Insertion of breathing tube down the throat into the lungs How did you hear about us? Veterinarian ReferralSearch Engine: (Google, Yelp, Bing, Angie's List, Yahoo, OtherWebsiteFriendStreet SignYellow PagesAdvertisementOther If you answered 'other', please give more details: Method of Payment (Please check one): Credit CardCheckCashOther Alpenglow VSEC is committed to providing high-level care at a reasonable cost, but the costs of veterinary treatment are often stressful and unexpected. Alpenglow Animal Critical Care + Emergency (AACCE) partners with a foundation called the Lady Bug Fund to ease the strain on our clients experiencing financial hardship in a pet emergency. If you would like to make a donation to the Lady Bug Fund to help a community member in need, please inform us, and one of our client care members will provide you with information on how, and where to donate. Treatment Authorization and Information/Photo Release I am the owner or the agent of the owner, of the above-described pet and have the authority to execute this agreement. I authorize Alpenglow Veterinary Specialty + Emergency Center (RMVC and/or AACCE and/or AMVS) to examine and treat the above pet. I have read and agreed to the financial policy of AVSEC, RMVC, AACCE, AMVS. I accept full financial responsibility for the pet. I understand that payment for diagnostic tests and treatment that I authorize in writing or verbally will be due at the time my pet is dismissed from the hospital. I also understand that if my pet is hospitalized by AACCE, he/she will need to be picked-up the next day prior to AACCE closing at 8:00AM. If another veterinarian has referred me to this hospital, I understand that they will receive a summary of the care and treatment provided by AVSEC, and/or (RMVC, AACCE, AMVS) in order to ensure that my pet’s care can be continued without interruption. I also understand that AVSEC, RMVC, AACCE, AMVS consider the identification of a referring veterinarian by me to be my authorization to release records and information to that veterinarian. Case information and/or photos may be used in teaching, continuing education, and veterinary literature. I authorize release of case/patient information for such purposes; patient confidentiality will be maintained. In the event of ownership transfer, I authorize the release of medical information to the new owner of this animal. Financial Policy Payment is due as services are rendered. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital. You may pay by cash, personal check, Care Credit, or Visa/MasterCard credit cards. In order to avoid any misunderstandings, please let us know immediately if these terms are not satisfactory. Checks will be made payable to one of the following: RMVC, AACCE, AMVS Authorized Signature: Date: Are you human? Then what is 2+1? *
