Owner Information

Owners Name (First, Last) *

First

Last

The person checking in a pet and making decisions must be at least 18 years old

Address *

Address Line 1

City

State

Zip Code

Email *

Primary Phone *

Secondary Phone *

Date of Birth of Primary Owner *

Driver's license of Primary Owner *

This is REQUIRED at check-in and is used for collections purposes ONLY. It will not be released outside of the hospital. A copy of your Driver's License is required for identification purposes.

Joint owner of Pet

A copy of joint owner's driver's license will be required if primary owner does not have one.

Joint Owner Name (First, Last)

First

Last

Phone Number

Additional Emergency Contact(s)

Name

First

Last

Phone Number

Pet Information

Pet Name *

Date of Birth *

Breed

Color/Markings

Species: *

Dog
Cat
Other

Sex *

Male
Female

Is your pet spayed or neutered? *

Yes
No

Does your pet have a microchip? *

Yes
No

Why are you seeking treatment today? *

Who is your regular Veterinarian? *

Have you been treated elsewhere for the symptoms described above? *

Yes
No

If previously treated for same symptoms, do you have a copy of records for that treatment? *

Yes
No

Is your pet aggressive? *

Yes
No

It is normal for nervous or sick pets to have changes in behavior

Is your pets reactive to strangers? Other animals? *

Is your pet current on all required vaccines? (Rabies vaccines are required by law) *

Yes
No

CPR Authorization

All clients who are seen for any examination at OWVUC, must designate their wishes regarding cardiopulmonary resuscitation (CPR) in the event that your pet stops breathing

CPR involves

Intubation
Chest compressions
Iv catheter placement
Administration of medications
Oxygen

Unfortunately, CPR does not guarantee a pet’s recovery.

If your pet can be resuscitated, they might experience the following issues:

Re-arrest
Changes in mentation
Rib fractures

If I authorized CPR, I agree to pay all costs involved with this attempted life-saving procedure and understand that a minimum of $700 will be in addition to previous signed estimates or deposits to cover the procedure.

I understand that Out West is unable to provide CPR without a doctor present.

If your pet develops the need for CPR, would you like resuscitation efforts performed?

Yes - perform CPR (starts at $700)
No - Do not perform CPR

Staff would be happy to answer any questions you might have about Cardiopulmonary Resuscitation

Authorization for Treatment, Risks and Emergency Care

I certify that I am the owner of the above-named pet, or an authorized agent of the owner, and have the authority to consent to veterinary care. I authorize the veterinarians and staff of Out West Veterinary Urgent Care to examine, diagnose, and treat my pet as they deem necessary. I understand that due to alternating schedules, the veterinarian responsible for my pet's care may change during treatment. I acknowledge that all medical procedures, anesthesia, and surgical treatments cárry inherent risks, including the possibility of serious complications or death. While every effort will be made to provide safe and effective care, no guarantee has been made regarding the outcome of treatment. Payment cannot be refunded if treatment is not successful. In addition, we are unable to provide refunds for prescription drugs once they have been opened and/or left the hospital. I understand that unexpected medical conditions may arise requiring immediate treatment. Staff will make all reasonable efforts to contact me before performing additional services. If I cannot be reached in a timely manner, I authorize the veterinarians and staff of OWVUC to provide any medical treatment they deem necessary for my pet's health and safety. If CPR is performed, I understand that resuscitation efforts are not guaranteed to be successful. *

I Understand

If the staff triage my pet and determine that it is critical requiring immediate treatment, a $750 deposit will be required so that we may attempt to help your pet. This deposit will help cover things such as medications, diagnostics, and/or radiographs, etc. It may not cover all initial diagnostics needed for stabilization. This deposit is applied to the overall invoice. *

I Understand

Examples of cases requiring an emergency deposit: gunshot wounds, unresponsive pets, actively seizing pets, snakebites, pets who have recently ingested toxins/objects, etc)

I also understand that any pet that is under two years old and exhibiting signs and symptoms of the Parvovirus must be tested. This will require a $350 deposit for testing. Please call us upon arrival and we will bring paperwork to your car. You and your pet must remain in the car until we have results from the Parvo test, as it is extremely infectious. Treatment decisions are always at the doctor's discretion. *

I Understand

If my pet is exhibiting coughing, hacking, sneezing, and has been to daycare, dog parks, groomers and boarders within the last 2 months, I will remain in the car and call the hospital for further instruction. The doctor must rule out "kennel cough" before bringing a pet into the hospital. *

I Understand

Financial Responsibility, Deposits, and Payments

I understand that a deposit equal to half of the high end estimate may be required prior to hospitalization, surgeries and emergency treatment. If a 3rd party financing option is being utilized, we will process the entire high end of the estimate prior to treatment. If the final invoice is less than what was originally processed, we will refund the difference.

I understand that payment is due in full at the time of discharge and that Out West Veterinary Urgent Care does not offer in-house payment plans, although we do accept several 3rd party financing options. To remain available to the community, we must collect payment for all services rendered. Failure to do so will result in submission of balance to a collection agency, and inability to seek services at Out West in the future. Billing charges are added to unpaid balances monthly until payment is received.

I understand that a deposit equal to the low end of the estimate may be required prior to hospitalization, surgeries and emergency treatment. If a 3rd party financing option is being utilized, we will process the entire high end of the estimate prior to treatment. If the final invoice is less than what was originally processed, we will refund the difference. I understand that payment is due in full at the time of discharge and that Out West Veterinary Urgent Care does not offer in-house payment plans, although we do accept several 3rd party financing options. To remain available to the community, we must collect payment for all services rendered. Failure to do so will result in submission of balance to a collection agency, and inability to seek services at Out West in the future. Billing charges are added to unpaid balances monthly until payment is received. *

I Understand

Hospital Policies

I understand that there are inherent risks during any sedated procedure. Pre-Anesthetic bloodwork is required for procedures involving anesthesia to help minimize risk.

I understand that the staff will do all that they can to treat your pet but outcomes are not guaranteed.

I understand that once an estimate has been signed, I am responsible for the balance due.

I understand that OutWest Veterinary Urgent Care will not tolerate any disrespectful or threatening behavior from clients, as we are obligated to protect our staff. If clients do not appear satisfied with services and begin to make the staff feel uncomfortable in any way, whether it be in person, on the phone, or through slanderous comments on social media, services may be terminated. It is absolutely necessary for clients to feel confident in our staff, and dissatisfaction will indicate a need to seek a hospital which can better suit your needs.

I understand that conversations with the medical staff are recorded so that they may be used in your pet's medical record. Out West does take photographs of some patients to be used for advertising, promotion or other commercial and business purposes on social media sites such as our website, Facebook and Instagram. These are used solely for education purposes, or to simply show off how precious your pet is!

I understand that there are inherent risks during any sedated procedure. Pre-Anesthetic bloodwork is required for procedures involving anesthesia to help minimize risk. I understand that the staff will do all that they can to treat your pet but outcomes are not guaranteed. I understand that once an estimate has been signed, I am responsible for the balance due. I understand that OutWest Veterinary Urgent Care will not tolerate any disrespectful or threatening behavior from clients, as we are obligated to protect our staff. If clients do not appear satisfied with services and begin to make the staff feel uncomfortable in any way, whether it be in person, on the phone, or through slanderous comments on social media, services may be terminated. It is absolutely necessary for clients to feel confident in our staff, and dissatisfaction will indicate a need to seek a hospital which can better suit your needs. I understand that conversations with the medical staff are recorded so that they may be used in your pet's medical record. Out West does take photographs of some patients to be used for advertising, promotion or other commercial and business purposes on social media sites such as our website, Facebook and Instagram. These are used solely for education purposes, or to simply show off how precious your pet is! *

I understand

Signature *

Clear Signature

By signing, I confirm that I am aware of all hospital policies, and am financially responsible for all treatment.

Printed Name *

Date *

Little Rock, AR

New ClientForm

How to Complete the Form

01

02

03

Need Immediate Assistance?

We’re Here for You and
Your Pet

Fill the New Client Form

Owner Information

Joint owner of Pet

Additional Emergency Contact(s)

Pet Information

CPR Authorization

Authorization for Treatment, Risks and Emergency Care

Financial Responsibility, Deposits, and Payments

Hospital Policies

Serving the Heart of Arkansas

Call Us When Your Pet Needs Urgent Care

Location

Contact Information

Hours

Little Rock, AR

New ClientForm

How to Complete the Form

01

02

03

Need Immediate Assistance?

We’re Here for You and Your Pet

Fill the New Client Form

Owner Information

Joint owner of Pet

Additional Emergency Contact(s)

Pet Information

CPR Authorization

Authorization for Treatment, Risks and Emergency Care

Financial Responsibility, Deposits, and Payments

Hospital Policies

We’re Here for You and
Your Pet