540-563-8575 evsroanoke@gmail.com

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Please Note: We are currently short-staffed so wait times may be extensive. We appreciate your patience at this time.
Please call before you arrive for more specific information regarding the current wait times. Thank you!

Online Check In

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

Complete the check in form online

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

Your Information:

Please let us know what car you drive:

Name *

First

Last

Address

Address Line 1

City

State

Zip Code

Email *

Phone *

Contact Preference:

Email
Phone

How did you hear about us?

Patient Information

Pet Name *

Regular Vet Hospital

Species

Dog
Cat
Other

Please specify

Gender

Neutered Male
Male
Spayed Female
Female

Pet Breed

Pet Age

Pet Color

Does your pet have any allergies, medications, or special problems? Please explain.

What does your pet need to be seen for today?

Have you been to Emergency Veterinary Services before?

Yes
No

What Year?

Has your pet experienced weakness, collapse, pale gums, difficulty breathing, seizures?

Yes
No

If your pet has experienced any of the above, please explain.

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? *

Cash
Credit Card
Care Credit
Scratchpay

Hospital Consent

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. *

I am the owner and I authorize this

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. *

I have read, understand, and consent

Signature *

Date *

Name

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