Client Information Form

Phone

This field is for validation purposes and should be left unchanged.

Which service are you here for today? Please choose one:*

Have you ever been to PVESC before?*

Yes
No

Reason for visit:

When did this start?

Parking Spot Number:

Arrival Time:

Owner

Name*

Address

Street Address Address Line 2 City State ZIP Code

Mailing Address (If Different):

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Cell or Home?

Cell
Home

Secondary Phone

Cell or Home?

Cell
Home

Email

Employer/Occupation

Co-Owner / Authorized Agent

Name

Primary Phone

Cell or Home?

Cell
Home

Secondary Phone

Cell or Home?

Cell
Home

Co-owner’s Email Address

Method of Payment

Payment Policy: Portland Veterinary Emergency and Specialty Care requires a Date of Birth and Driver’s license for all types of payments. Cash, credit cards (Visa, Mastercard, Discover and American Express), Care Credit and Scratch Pay are acceptable forms of payment. No personal, third party, or business checks are accepted.

Owner Date of Birth:

Owner’s Driver License #/State:

Pet Information

Pet's Name:

Dog / Cat / Other

Other

Breed

Color

Date of Birth/Age:

Sex

Male / Neutered

Yes
No

Female / Spayed

Yes
No

Vaccine History

Rabies

Distemper

Lyme

Lepto

Leukemia

List of ongoing health conditions:

List of Pet's Medications:

Regular Veterinary Clinic

***Your pet may be photographed while in our care. May we use your pet’s photo on our website or Facebook page?*

Yes
No

***How did you hear about us?*

Family Veterinarian
Google Listing
Facebook
Word of Mouth
News Paper or Magazine Ad
Movie Theater Ad

Authorization: I (owner or authorized agent for the owner) hereby authorize Portland Veterinary Emergency and Specialty Care veterinarians and staff to examine, prescribe for, and treat the pet described above. Further I understand: That no guarantee of successful treatment is either made or implied. No assurance or guarantee has been made of the results of sedation, anesthesia, surgery and/or treatment and the probabilities of complications exist in any sedation, anesthesia, surgery and/or medical treatment. I assume full responsibility for all charges incurred in the care of said animal and understand all fees must be paid in full upon completion of services and prior to discharge of the animal from Portland Veterinary Emergency and Specialty Care. Should said animal have to be hospitalized or should a surgical procedure be performed, a deposit amounting to 50% of the high end of the estimated fees is required for ALL surgeries and hospitalized patients. Radioactive Iodine Therapy requires payment in full prior to admission. PVESC reserves the right to treat any pet presented with fleas with an oral medication to treat the immediate situation. There is a charge for this treatment. Please Note: If for any reason you are unable to pay your account in full and your account is sent to collection, PVESC reserves the right to add 50% of the balance due to your account to cover collection costs.

Owner Signature:*

Date

Co-Owner / Authorized Agent Signature:

Date

Information provided is for Portland Veterinary Emergency and Specialty Care use only. No information is disclosed, sold or given to 3rd parties

If you are here for an emergency, please call our office after you submit this form and have secured your parking spot. 207-878-3121