• Home
  • Services
  • Reviews
  • Payment Options
  • Emergency Info
  • Pet Tales
  • Client Information Form

    Client Information Form

    At Animal Emergency Clinic of San Diego, we offer patient forms online so you can complete them at the convenience of your own home or office. You may email us the completed forms or bring them with you on your next visit.
    ​​​​​​​

    • If you do not already have AdobeReader® installed on your computer, Click Here to download.

    • Download the necessary form(s), print it out, and fill in the required information.



    Client Information Form

    DOWNLOAD


    Submit your form online

    You may also submit the forms online. Please fill up and submit the form below:

    *Required field.

    Date:

    Name:

    Co-Owner's Name:

    Address:

    City:

    State:

    Zip Code:

    Primary Phone*

    Secondary Phone

    Email*

    **This line is for DEA reporting records only.
    Owners/Agent Date of Birth

    Additional Authorized agent for Pet

    Name

    Phone

    PET INFORMATION

    Pet Name*

    Age

    Species

    Breed

    Color

    Sex

    What is your reason for bringing your pet in today?

    Does your pet have any previous medical problems, conditions, or allergies?

    Is your pet on any current medications, or have you given any medications?

    What is your pet's normal diet?

    ADDITIONAL INFORMATION

    Who is your Pet's Regular Veterinary Hospital? ( We will send records from your visit today.)

    How did you hear about our Hospital?

    Do we have your consent to post pictures of your pet on our website/social media?

    SIGNATURES

    I, the undersigned, owner, or agent of admitting patient and age 18 or over, hereby authorize the attending Veterinarian (and whomever they may designate as their assistant) to examine said patient. Treatment options will be discussed after said evaluation and then as needed. The risks and nature of the procedure(s) will be explained to me, and no warranty or guarantee will be made as to the result or cure. Payment is due at the time services are rendered. A deposit is required on admitted patients, and balance is due upon animal’s release. Animals must be picked up by 8 am Monday through Friday or additional charges may incur.

    Signature of Owner/Authorized Agent*