Client Information:

First Name: *

Last Name: *

Email Address: *

Phone Number: *

Home Address: *

City: *

Province: *

Postal Code: *

Co-owner:

First Name:

Last Name:

Phone Number:

Email Address:

Is also able to make medical decisions on my pet's behalf:

Yes

No

Primary Care Veterinarian: *

How did you find out about us?

Do you have pet insurance?

Insurance Provider:

Pet Information:

Patient Name: *

Species: *

Breed: *

Sex: *

Color: *

Date of Birth: *

Estimated Age:

Presenting Concern: *

Current Medications:

Comments:

Photographic/Social Media - Consent

I agree to allow the Burlington Veterinary Emergency & Referral Hospital to take and use photographs and radiographs/other imaging of my pet for any lawful purpose, including for example such purposes as publicity, illustration, education and web content.

I authorize the Burlington Veterinary Emergency & Referral Hospital, it assigns and transferees to copyright, use and publish the same in print and/or electronically.

I do not authorize.

Initials:

Recording of Verbal Conversations - Consent

To enhance the accuracy and efficiency of our medical records, discussions in person and/or over the phone during my pet’s visit may be recorded using AI dictation technology.

I consent to the recording of all discussions during my visit for the purpose of medical record keeping and training.

I do not consent.

Initials:

Any hospitalization, treatments and/or medication are in addition to the Emergency Consultation/Examination fee of $200+HST. A deposit of 100% of the low end of the estimate is needed for admitted patients.
Payment in full is due at the time of discharge. We accept Visa, Mastercard, Debit, Amex, and Cash.
We do not accept cheques.

Initials:

Date

Spam Blocker

Emergency Intake Form

Client Information:

Co-owner:

Pet Information:

Photographic/Social Media - Consent

Recording of Verbal Conversations - Consent

Emergency & Specialty Veterinary Referrals Welcome