Owner Details
Name
*
First Name
Last Name
Pronouns
Email
*
example@example.com
Primary Phone Number
*
-
Area Code
Phone Number
Authorization to send text messages. By selecting “accept" and signing below, you consent to receive email and/or SMS text messages from us. Message rates vary. Not all carriers are covered. Standard message and data rates apply. You may update your preference, and cancel your consent, by notifying us at any time or by replying CANCEL/STOP to any message you receive from us
I decline and DO NOT want to receive text messages.
I accept and DO want to receive text messages.
Secondary Phone Number
-
Area Code
Phone Number
Authorization to send text messages. By selecting “accept" and signing below, you consent to receive email and/or SMS text messages from us. Message rates vary. Not all carriers are covered. Standard message and data rates apply. You may update your preference, and cancel your consent, by notifying us at any time or by replying CANCEL/STOP to any message you receive from us
I decline and DO NOT want to receive text messages.
I accept and DO want to receive text messages.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Patient Details
Regular vet clinic
*
If Banfield or Companion, please specify which location
Pet's name
*
Canine or Feline
*
Canine
Feline
Other
Breed
Color of pet's fur
Sex
*
Female
Male
I don't know
Spayed / Neutered
*
Yes
No
I don't know
Approximate age
*
What is the reason for your visit today?
*
Do you give consent for immediate treatment of your pet? - Cost of treatments required to stabilize your pet's condition, including but not limited to: examination, intravenous catheterization and fluid administration, rapid diagnostic tests, and emergency medication may range from $250-$500, but can exceed this in very critical situations.
*
Yes, I give consent for immediate treatment and accept the payment conditions.
No, I do NOT give consent for treatment and wish to speak to a doctor first, even though this may delay the treatment of my pet. I will not hold Tanasbourne Veterinary Emergency responsible for any adverse outcomes that this delay may cause.
In the event that my pet arrests while being treated, I authorize C.P.R. code:
*
C.P.R. - potentially involving chest compression, oxygen therapy and medications.
D.N.R. - No resuscitation
Balance due at time of service. We accept AmEx, Visa, MC or discover. For same-day financing, you can set up an account with either Scratchpay.com or CareCredit.com prior to check out today. Please type your full name below to agree:
*
Full Name
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Patient History
What symptoms are you seeing today?
*
scratching, sneezing, etc.
Allergies or sensitivities
*
medications, food, etc.
Current medications
*
allergy, flea prevention, supplements, etc.
Current diet, favorite treats
*
Current medical issues
*
FIV, fleas, etc.
Past medical issues
*
FIV, fleas, etc.
Has your pet ever had a blood transfusion?
*
Yes
No
I don't know
Pet's travel history
river/lake/fish exposure/born in another area/travel outside Oregon
Vaccine status
*
Current
Some in the past
I don't know
None
Lifestyle
*
indoor/outdoor, couch potato/athlete
During the course of treatment, we often come across pets or medical conditions we would like to feature on social media or in marketing materials. Do you give consent for Tanasbourne Veterinary Emergency to take photos of your pet for use on social medial, marketing, and educational materials?
Yes, I release TVER to take photos of my pet for use on social media, marketing, and educational materials.
No, I DO NOT want TVER to take photos of my pet for use on social media, marketing, and educational materials.
Submit
Help us identify you and your pet
What will you be driving when you drop off/pick up your pet?
make, model, color
Would you share a photo of your pet with us? Please select an image and click the upload button.
Should be Empty: