Client Intake Form - BluePearl Pet Hospital

Choose a Hospital*
Owner Name*
Co-Owner's Name
Address*
Apt. #
City*
State
ZIP code*
Cell Phone*
Alternative Phone
Email Address*
Pet's Name*
Species*
Breed*
Color*
Date of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
Sex*
- Female Intact
- Female Spayed
- Male Intact
- Male Neutered
Does your pet have a history of fear, anxiety, aggression or biting?*
Referring Hospital*
Referring Veterinarian*
Additional Veterinarians
Reason for Visit*
- Emergency/Urgent Care
- Specialist Visit
- Comfort Care (Hospice)
Reason for Visit Details*
Please list any health problems and current medications*
Please list any pet health insurance you have
Where we deem necessary, our default is to take life-saving measures to stabilize your pet, which may include resuscitation. You may choose to update your preference for emergency medical directive during consultation with our medical team.
Consent to Treat
I, the undersigned, do hereby certify that I am over the age of 18 and am the owner (or authorized agent) of the above-described patient. I authorize BluePearl Specialty and Emergency Pet Hospital (and its affiliates, employees, agents and contractors) to receive, examine, prescribe for and treat the above-described pet. I further understand that no guarantee of successful treatment is made and I will not hold BluePearl Specialty and Emergency Pet Hospital (or its affiliates, employees, agents or contractors) responsible for my pet’s recovery.
Payment Policy
A deposit will be required prior to treatment and/or hospitalization. Full payment for services rendered is required prior to discharge of your pet from the hospital. I am aware that all diagnostics, treatment and medication charges are in addition to any examination fee and agree to pay all charges incurred at the time of service. In the event of a check returned NSF or stop payment, a $25 fee will be added to the account. Late payments are subject to a late charge of 1.5% each 30 days or less. Any collection costs including reasonable attorney’s fees will be borne by me, the customer.
Records and Communication Policy
BluePearl Specialty and Emergency Pet Hospital is part of your pet’s continuum of care, and we may provide your family veterinarian, any specialists, and/or a reviewing body information regarding your pet’s treatment and/or condition. By signing below, you are authorizing BluePearl Specialty and Emergency Pet Hospital to share your pet’s medical record with a third party (such as your family veterinarian) or its agent necessary for us to provide continuous veterinary care to your pet. You agree that we (or our agents) may send you communications to your contact information provided above regarding your pet.
Client Signature*
Date*
MM slash DD slash YYYY
Data Privacy Notice
BluePearl and our affiliated entities are committed to providing quality and informed services to and for you and your pet. We aim to be your partner in your pet's long-term health and happiness through a variety of means, including by considering research, diagnosis and analysis from across our vet hospitals and brands. As part of this mission, we work with our affiliates, parent and subsidiaries to provide the services you request and to analyze and evaluate the patterns of diagnosis and treatment of the pets treated at our facilities. From time to time we, BluePearl, and our affiliates, may also use the data collected from you and your pet for research and for advertising and promotion of goods and services that may be of interest and beneficial to you and your pet. For more information on our policies and information on how to opt-out of some forms of sharing, please see our Privacy Policy at https://www.mars.com/privacy.
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Client & Patient Intake Form

Consent to Treat

Payment Policy

Records and Communication Policy

Data Privacy Notice