Please Complete and Submit this form online prior to your arrival at SSV.

Reason forUrgent Care Visit? *

Please upload any pertinent Medical Records

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Important Client Information

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Owner Cell Phone *

Owner Landline

Owner Work Phone

Owner Email *

Spouse/Partner Name

First

Last

Spouse/Partner Cell Phone

Spouse/Partner Email

If we are Unable to reach you, who may we contact in case of emergency? *

First

Last

Emergency Contact Phone *

Do you authorize this person to make urgent treatment decisions if you are unreachable?

Yes
No

Please list people and their phone numbers in addition to you primary care veterinarian to whom we may release information.

How did you hear about us?

Who is your referring doctor (if applicable)?

Do you have a primary care doctor? *

Yes
No

If yes, please enter your Doctor's Name *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Information

Patient Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color *

Weight *

Sex *

Male
Neutered Male
Female
Spayed Female

Name, Email, and Phone Number of your primary veterinarian. *

By listing your primary care veterinarian above, you are authorizing our hospital to release patient information to the hospital or veterinarian(s) listed. *

I understand

Why are you seeking an ER-Urgent Care visit? *

If this is an ongoing issue, how long has it been being treated?

Upload medical records from Veterinarian (pDVM) who has treated this problem in the past.

Drag & Drop Files, Choose Files to Upload You can upload up to 15 files.

Other Important Information

Please upload latest Rabies certificate:

Drag & Drop Files, Choose Files to Upload

Has your pet ever had an adverse effect to Anesthesia or Sedation in the past? Please be detailed. *

Does your pet have an allergy to any drugs or medication? Please be detailed. *

I hereby authorize SV to render medical care for my pet (s) as deemed necessary by the veterinarian. *

Yes, I understand

I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. *

Yes, I understand

I understand that a deposit toward themedical plan isrequired before diagnostics and treatments can be initiated. *

Yes, I understand

I agree to pay for the cost of all services to which I grant verbal or written consent. *

Yes, I understand

I understand that payment in full is required prior to the discharge ofmy pet from SSV. *

Yes, I understand

I understand that in the event of any unusual or emergency circumstances, the staff of SSV ER-Urgent Care is authorized to render any treatment they deem necessary for the health of my pet(s. Astaff member will, time permitting, attempt to contact me or my designated representative, before proceeding with any emergencytreatment. In any event I acknowledge that I will be financially responsible for any emergency treatments. *

Yes, I understand

Please Upload a picture of your pet!

Drag & Drop Files, Choose Files to Upload

Signature *

Clear Signature

Date *

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Milford, CT

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Important Client Information

Patient Information

Other Important Information

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