Check-In Form

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Critical Condition: If your pet’s condition is critical or life-threatening, please call the Central Orange County Emergency Animal Hospital (COCEAH) immediately instead of waiting for a response to this form.

Client Information

Pet Information

Date of Birth

Emergency Information

Has the pet been treated for the same issue before?

Primary Veterinary History

Payment Information

No personal check is accepted.

Do you have Pet Insurance?

Consent Information

Consent 1
Consent 2
Consent 3
Consent 4

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.”

Authorization Statement

Supplementary Information

Click or drag a file to this area to upload.

Data Privacy and Handling

“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.”

Data privacy

Client Signature

Central Orange County Emergency Animal Hospital Newport Beach, CA