Registration Form

Complete the registration form online

Please fill out this online registration form before you arrive. Once the form is complete, please come in for your appointment.

Please call us before you arrive for an update on our current wait times. We appreciate your patience and understanding. Thank you!

 

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"*" indicates required fields

Pet Owner Information

Owner Signature:*
Co-owner:
Address:*

Contact Details

Please enter the information of the primary contact (the designated person who will be contacted with updates for the patient and making decisions).

If this is not you, please put your information as the co-owner.
Contact Preference:*

Patient Information

Have you been to Emergency Veterinary Services before?
Has your pet experienced weakness, collapse, pale gums, difficulty breathing, seizures?

Payment Information

Payment for services is due at the time rendered. Accounts remaining unpaid will incur interest at a rate of 18% per annum. If the account becomes delinquent and is turned over to collections, the undersigned agrees to assume all costs and expenses incuding collection fees, certified letter fees, and all court costs and attorney's fees. How do you intend to pay today?*

Hospital Consent

I am the owner or agent of the owner of the above-described animal and have the authority to execute this consent. I hereby authorize the performance of such procedures or operations as explained by Emergency Veterinary Services of Roanoke, INC.*

Emergency Veterinary Procedures

I understand that unforeseen conditions may require an extension of a planned procedure or operation. I hereby authorize the performance of such procedures or operations as are necessary and advisable in the opinion of the Veterinarian. I understand that I assume all risks and that results cannot be guaranteed. I have read the foregoing and consent and authorize to the treatment required and the terms contained herein.*
Owner:*
This field is for validation purposes and should be left unchanged.