Tanasbourne Veterinary Emergency

Owner Details
Name*

First NameLast Name
Pronouns
Email*
example@example.com
Primary Phone Number*

Area CodePhone 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 CodePhone 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

CityState / Province

Postal / Zip Code

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?*

YesNoI don't know
Pet's travel history
river/lake/fish exposure/born in another area/travel outside Oregon
Vaccine status*

CurrentSome in the pastI don't knowNone
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.
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:

Owner Details