Today's Date

Estimated Time of Arrival

Client Information

Client First Name

Family Name

Primary Phone Number

Secondary Phone Number

Email*

Street Address

City

State

ZIP Code

Pet Information

Pet's Name

Species

Date of Birth

Breed

Age

Sex

Spayed/Neutered

Yes No

Emergency Information

Description of Emergency

Onset of Symptoms

Has the pet been treated for the same issue before?

Yes No

Current Medications

Primary Veterinary History

Name of Primary Veterinary Clinic

Payment Information

No personal check is accepted.

Preferred Payment Method

Do you have Pet Insurance?

Yes No

Consent Information

I understand that this is an Emergency Animal Hospital and that payment is due at the time of service.

I understand that if I do not pick up my pet at the time required, Sec. 1834.5 of the CA Civil Code shall deem my pet abandoned, and I may face criminal charges.

I understand that COCEAH is not open 24 hours per day. Unless a special arrangement is made, all patients must be discharged before closing each day at 8:00AM (except Sundays and Holidays). If my pet requires further care, I understand that I will need to transfer my pet to my family veterinarian for continued care.

I consent to my data being stored and used for the purpose of managing my pet’s emergency care.

Authorization Statement

“I certify that I am the owner, or the authorized representative of the owner, of the pet listed on this form and am over 18 years of age. I hereby authorize the attending veterinarian at the Central Orange County Emergency Animal Hospital (COCEAH) to examine, prescribe for, and treat my pet as deemed medically necessary by the attending veterinarian. The necessity for diagnostic procedures, therapeutic treatments, and/or hospitalization has been thoroughly explained to me. I understand that the treatment provided by COCEAH is on an emergency basis, and that I am required to follow up with my regular veterinarian for additional treatment, diagnostic procedures, and hospitalization as necessary. I acknowledge that I am financially responsible for all charges as they are incurred, and that I am obliged to make additional payments every 12 hours if my pet is hospitalized. I understand that COCEAH will keep me updated regarding additional treatments as needed.”

I confirm that I have read and agree with the above authorization.

Supplementary Information

Please upload any relevant medical documents or images below.

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Data Privacy and Handling

Content

“We value your privacy and are committed to protecting your personal data. The personal data collected in this form will be used exclusively for the purpose of providing veterinary services to your pet and communicating with you. We have measures in place to protect your personal data from unauthorized access, alteration, and deletion. We will not share your personal data with third parties without your explicit consent.”

I have read and agreed to the terms.

Client Signature

By signing or typing my full name below, I confirm that all the information provided is accurate and I accept all terms and conditions outlined above.

Check-In Form

Client Information

Pet Information

Emergency Information

Primary Veterinary History

Payment Information

Consent Information

Authorization Statement

Supplementary Information

Data Privacy and Handling

Client Signature