Owner first name*

Owner last name*

Co-owner's first name

Co-owner's last name

Street address*

City*

State*

ZIP code*

Primary phone number*

Co-owner phone number

Email address*

Do you have a location preference?*

Ellicott City

Frederick

First available

Do we have permission to use photos of your pet for social media?*

Yes

Pet's name*

Species*

Canine

Feline

Breed*

Pet's date of birth (mm/dd/yyyy)*

(Estimated DOB is fine)

Last known weight (in pounds)*

Sex*

Female intact

Female spayed

Male intact

Male neutered

Primary veterinary hospital*

Please specify location if your veterinarian has multiple hospitals (e.g., Banfield, VCA, etc.)

Primary veterinarian*

Does your pet have a history of fear, anxiety, aggression, or biting?*

Yes

Please describe your pet's history with fear/anxiety/aggression/biting*

Please include if your pet requires calming/sedative medications before visiting your veterinarian.

Presenting concern (please include affected limb and symptoms of injury)*

Examples: "My primary veterinarian diagnosed Bailey with a right CCL" or "Bailey has not been using her right hind leg for about two months after she fell chasing a squirrel in the backyard."

Approximately how long ago did you first notice your pet's symptoms?*

Have your pet's symptoms change since onset? (Improved, worsened, fluctuated, etc.)*

If your pet has been evaluated by your primary care veterinarian for this condition, please provide the diagnosis and approximate date evaluated.*

Has your pet been evaluated by any other veterinary professionals for this condition?*

Yes

Emergency, chiropractor, rehab therapist, cardiologist, neurologist, dermatologist, etc.

Please provide clinic information and approximate dates.*

As part of our standard intake process, we will request your pet's medical records prior to contacting you in order to expedite scheduling and ensure we have the most accurate information. Do we have your permission to contact the veterinary practices you’ve listed?*

Yes, I give permission

No, I do not give permission

Has your pet had diagnostics performed in the last 12 months?*

X-rays

Bloodwork

Diagnostic imaging (ultrasound/CT/MRI)

None

If applicable, are you interested in surgical intervention?*

Yes

Unsure

Is your pet currently on any medications and/or supplements?*

Yes

Please list your pet's current medications/supplements.*

Are there any medications that your pet cannot have or that your pet has had an adverse reaction to?*

Yes

Please list any medications your pet cannot have or has had an adverse reaction to.*

Please list any other health concerns.*

Have any of your pets been evaluated by Skylos in the past?*

Yes

Is your pet insured? (Trupanion, Embrace, etc.)*

Yes

If you have been referred to us due to a fracture that has occurred, please upload the radiographs (if available) to help expedite scheduling your pet's appointment.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 256 MB.

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.

Records and Communication Policy

BluePearl 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*

Data Privacy Notice

BluePearl Pet Hospital 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 clinical studies, diagnosis and analysis from across our veterinary 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 Specialty and Emergency Pet Hospital, and our affiliates, may also use the data collected from you and your pet for advertising and promotion of goods and services that may be of interest and beneficial to you and your pet. In addition, we may use such data and/or any residual biological samples collected from your pet for clinical studies to advance veterinary knowledge. Please visit our privacy policy for more information about the collection and use of your data and how to opt out of some forms of sharing.

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Consent to Treat

Records and Communication Policy

Data Privacy Notice