Intake Form

When you arrive at Chicago Veterinary Emergency and Specialty Center, you will be asked to provide the following information. Please come prepared with answers to these questions and read the authorization information which you will be asked to sign. Or, download the PDF at the bottom of the page and bring the completed form with you. Thank you.

Your Name
Your Mailing Address
Your Phone Number
Your Email Address

The Referring Hospital and Phone
Referring Doctor’s Full Name
Your Pharmacy and Phone

Information about your pet:
Your Pet’s Name
Your Pet’s Breed
Your Pet’s Color
Your Pet’s Age
Your Pet’s Sex

Reason for today’s visit.
Time of pet’s last meal.
Your Pet’s current medications.
Time last medications were given.
Did you bring the medications with you today?
Your preferred contact number TODAY.
Any special instructions.

AUTHORIZATION FOR EXAMINATION, TREATMENT AND ASSUMPTION OF FINANCIAL RESPONSIBILITY
I, the undersigned, authorize the veterinarian(s), technician(s) and assistant(s) to examine the animal(s) specifically described and identified and to administer emergency medical and/or surgical treatment (including administration of anesthetics) that is considered therapeutically and/or diagnostically necessary based on the finding during the course of ther initial exam. This includes ongoing treatments. I understand that the treatment of the patient will be conducted with due care and in accordance with the prevailing standards of competency in Veterinary Medicine and that during the performance of this procedure(s) unforeseen events resulting from the procedure(s) will not relieve me from any obligation for all reasonable cost incurred regarding this animal. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by CVESC, its veterinarians, agents or employees. I assume all financial responsibility for all charges incurred to the patient; consent to the release of medical information; and authorize the direct payment to the Chicago Veterinary Emergency and Specialty Center. I understand and agree to pay all charges in full upon completion of services and that a deposit may be required prior to treatment. If I do not pay the entire new balance within 30 days of the monthly billing date, a service charge of 1.5% and a billing fee of $5.00 will be added for the current monthly billing period. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to affect a collection of this account or future outstanding accounts. I understand that I may pay with Cash, Check, Visa, Mastercard, American Express, Discover or Care Credit.

I understand and agree that CVESC is not responsible for the patient’s personal valuables and it is recommended that I take them when the patient is admitted to the hospital.

Download a PDF of this form to print, fill out, and bring with you.