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New Client Form

Save time at your next appointment! Please complete your required New Client Form online from any device at any time before your visit.

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New Client Form

Please complete this form completely and accurately so that we can get to know you and your pet(s) before your visit. If this is an emergency or your pet requires immediate attention, please call us at 757-410-5533 for a faster response.

Step 1 of 3

Where was your pet(s) last seen for vaccinations/ treatment?

Do we have permission to acquire previous vaccine and medical history ?

What heart worm / intestinal parasite preventative is your pet on? Flea preventative?

Has your pet ever experienced a reaction to any vaccination, medication or anesthesia?

Do you or anyone in your family suffer from significant allergic conditions we should be aware of (food, or other) as we use many different treats to help your pet acclimate to our staff and office?

PAYMENT IS REQUIRED IN FULL AT THE TIME OF SERVICES, BEFORE THE PATIENT IS RELEASED.

We accept cash, check, Visa, Master Card, Discover and Care Credit as forms of payment.

Statement of Ownership and Consent: I am the owner and/or agent of the above animal(s) and have the authorization to consent to treatment if and when it is needed. By signing this agreement, I authorize Barker Animal Hospital staff to provide care and perform and treatment, including the administration of anesthesia and surgical procedures they consider reasonable and necessary for my animal, and I consent to any such services. I understand that with any medical or surgical procedures there are always risks involved, including death, and that no warranty or guarantee is being made as to the results or cure.

Vaccines: Most pets respond well to vaccines but as with any medical procedure, vaccinations are not risk free. The most common adverse responses are mild and short term including: fever, sluggishness, reduced appetite, and sometimes temporary discomfort or subtle swelling at the vaccination site. Rarely serious adverse reactions occur. Contact us immediately if any of the following occur: vomiting, diarrhea, whole body itching, difficulty breathing, collapse, or swelling of the face or legs. Remember that while vaccination is not without risk, failure to vaccinate leaves your pet vulnerable to fatal illnesses that are preventable. Sarcomas are a form of cancer in cats that may be related to vaccines. Vaccine injection sites should be monitored for swelling and if a lump is noticed it should be checked by your veterinarian. Although there is a risk to giving vaccines it is still recommended you vaccinate your cat; cats are at far greater risk of acquiring a fatal infection than any risk the vaccine may pose.

Signature of Responsible Party *

Clear Signature

Date *

GENERAL STATEMENT:

We at Barker Animal Hospital thank you for giving us the opportunity to care for your pet and want you to know that we do not take this responsibility lightly. In the unlikely event your pet suffers respiratory arrest (stops breathing) or cardiac arrest (heart stops beating) while in the care of Barker Animal Hospital, we are fully prepared to meet such a challenge should it occur and want to be aware of your wishes when caring for your loved one in order to meet both your emotional and financial needs.

CARDIOPULMONARY RESUSCITATION (CPR) AUTHORIZATION:

I understand that CPR is tailored to meet the medical needs of the individual patient but may include any or all of the following:

Establishing an airway via placement of an endotracheal tube and administering oxygen or medications through the tube; establishing intravenous (IV) access via placement of an intravenous catheter and administering fluids and/or injectable medications through the catheter; chest compressions; or intracardiac delivery of injectable medications.

I understand that all costs incurred in the process of resuscitating my pet will be charged to my bill (minimum of $300 prior to calling me).

I understand that the resuscitation process will be started prior to being able to contact me, but that a medical professional will contact me within 15 minutes of starting CPR. I take full financial responsibility for these costs even though death may occur due to the severity of the injury or illness.

I understand that animals that have survived cardiopulmonary or respiratory arrest and have been successfully resuscitated (CPR) are extremely critical and unstable. The likelihood of re-arrest is high and usually occurs within 4 hours of the initial arrest. Management of the post-arrest patient requires vigilant monitoring for at least 24-48 hours by dedicated critical care personnel. This care can be costly and the outcome is uncertain.

By checking YES below: I hereby authorize Barker Animal Hospital to perform CPR (cardiopulmonary resuscitation) when and if a veterinarian deems it necessary for my pet in an attempt to stabilize my pet's condition. Having requested such procedure(s), I agree to be held responsible for a minimum of $300 over and above my estimate. I understand that despite the best efforts of the doctors and staff, there is the chance that my pet may not survive. I understand that even the most successful CPR that restores my pet's life may not allow him/her to regain normal mentation and/or physical health and may leave him/her as an invalid. I am aware that there are risks and complications involved with CPR.

DO NOT RESUSCITATE (DNR): By selecting NO below; I understand that I am declining CPR (cardiopulmonary resuscitation) in the event that it is deemed necessary by a veterinary medical professional for the survival of my pet. I understand that by putting a DNR (Do Not Resuscitate) order on my pet, the medical staff will not perform or give possibly life-saving procedures or medications.

Please select your response below for the patient listed.

Pet #1 (Name)

Authorization

YES, I authorize Barker Animal Hospital to perform CPR.
NO, I do NOT authorize Barker Animal Hospital to perform CPR. I choose a DNR order for this patient.

Pet #2 (Name)

Authorization

YES, I authorize Barker Animal Hospital to perform CPR.
NO, I do NOT authorize Barker Animal Hospital to perform CPR. I choose a DNR order for this patient.

Pet #3 (Name)

Authorization

YES, I authorize Barker Animal Hospital to perform CPR.
NO, I do NOT authorize Barker Animal Hospital to perform CPR. I choose a DNR order for this patient.

Name

*This promotion is valid for new clients only and may be used once per client. Cannot be combined with other offers or promotions. Other restrictions may apply.

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