AEC Check-In

Pet's first name : Species : Breed / Type :

Age :

Unit :

Color : Sex : Spayed / NeuteredReason for today's visit : Has this pet been to Animal Emergency Center before?Is this pet a patient of Veterinary Cardiology Consultants?Is this pet a patient of Veterinary Vision of Rochester?

Who is your pet's regular veterinarian?

Dr : Clinic Name : Phone : Is your dog / cat current on vaccines? May we share your AEC medical records with others that provide care for your pet?

What is your relationship to this pet?First Name : Last Name : Address : City : State : ZIP : E-Mail : Cell Phone : (this is the primary number we will use for updates and text messaging)Alternate Phone :

Who is this contact?First Name : Last Name : Address : City : State : ZIP : E-Mail : Primary Phone : Alternate Phone :

Occasionally we may wish to share a patient photo in a social media post, on our website or other media. Please indicate if you give AEC permission to include photo(s) of your pet:

By clicking 'Agree' and submitting this information online, I signify the following:

I am the owner of the above listed pet, or I am authorized by the owner to act on their behalf. I give permission to proceed with an initial pet examination to determine appropriate treatment.

I understand and agree that I am liable for any and all fees and costs associated with the initial pet examination and additional approved treatment(s) received by this pet (if acting on behalf of the owner, both the owner and I are personally liable, jointly and severally). I agree to pay such fees and costs when requested to do so. I understand that all payments for treatment(s) received by the pet must be paid prior to the pet's release, and if payment is not made in full when the pet is scheduled for release, there will be additional fees and costs associated with boarding and otherwise caring for the pet until the pet is released.

I understand that while Animal Emergency Center (AEC) will strive to provide this pet with the best possible treatment(s), AEC cannot guarantee any results of the treatment, and that payment is not conditioned on receiving any particular results.

I Agree

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