Client Registration & Consent | South Metro Animal Emergency Care

Please ensure that you have called us at (952) 953-3737, and that you will be bringing your pet to us, so that we can expect the required forms prior to your arrival.

Contact Information

Owner Name*

First Last

Email*

Enter Email Confirm Email

Immediate/Mobile Phone*

Alt. Mobile/Home Phone*

Address*

No P.O. Boxes

Street Address City State ZIP Code

Car Color, Make & Model*

Pet Health History

Pet Name*

Species*

Dog
Cat

Sex*

Intact Male
Neutered Male
Intact Female
Spayed Female

Age*

Breed(s)*

Color(s)*

Regular Veterinary Clinic*

Reason(s) for Visit*

Are vaccinations current?*

Yes
No

Previous Medical Problems*

Current Medications*

Chemotherapeutic Drugs*

Known Allergies*

How did you hear about us?

Client Consent

PAYMENT REQUIRED AT TIME OF SERVICE
ALL ANIMALS MUST BE PICKED UP BY 7:30 A.M. WEEKDAYS
DEPOSIT REQUIRED ON ALL HOSPITALIZED ANIMALS

I hereby authorize South Metro Animal Emergency Care and its staff to evaluate and treat my pet. I will be responsible for the standard Emergency Exam Fee of $144.00 and any diagnostics or initial treatments verbally agreed to prior to a written estimate. No guarantee of successful treatment is made. I will not hold the emergency facility responsible for my pet’s recovery and agree to pay all charges incurred at the time of release of my pet.

In the event my pet is hospitalized, I will need to leave a deposit at the front desk and return the next regular business day by 7:30 a.m. to transfer my pet to my regular veterinarian for further care.

I further understand that my pet must be picked up when instructed or alternative transport by a family member or other authorized party must be made known to staff by the primary owner, and additional consent may be required for such transport to be enabled. Appropriate hospital and late fees will be incurred until the pet is released.

Consent to Distribute Medical Records

I authorize: South Metro Animal Emergency Care to release copies of my pet's medical records and supporting documents such as radiographs and diagnostic results to the primary physician of my choice.

I understand that this information shall be in effect for 1 year following the date of signature. However, I understand that this authorization may be revoked at any time by giving oral or written notice to SMAEC. I understand that once my pet's medical records have been released, the medical office cannot retrieve them and has no control over the use of the already released copies.

Media Authorization

I understand that South Metro Animal Emergency Care may take pictures and/or videos of my pet for continuing education, medical publications, or promotional purposes. These images will have no identifying information about me or my family associated with them. They may contain my pet's name. I will claim no ownership of or authority over said media documents.

Media Authorization*

I authorize South Metro Animal Emergency Care to take pictures and/or videos of my pet for continuing education, medical publications, or promotional purposes.
I do NOT authorize South Metro Animal Emergency Care to take pictures and/or videos of my pet for continuing education, medical publications, or promotional purposes.

Signature of Owner or Authorized Agent*

I am at least 18 years of age or older.
Typing or writing your full name below holds authorization equal to that of written signature.

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