• Date
     - -
  • Time
  • Client Information

  • Format: (000) 000-0000.
  • Would you like to list a Co-Owner on your account?
  • Format: (000) 000-0000.
  • Pet Information

    • Pet 1 Information 
    • Pet 1: Species*
    • Pet 1: Is it an indoor or an outdoor pet?
    • Pet 1: Is your pet microchipped?*
    • Pet 1: Does your pet have any known allergies or drug reactions?*
    • Pet 1: Is your pet currently being treated for any medical conditions?*
    • Pet 1: Has this pet had any previous medical problems or issues?*
    • Pet 1: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name and personal information.*
    • Pet 2 Information 
    • Pet 2 Information

    • Pet 2: Species*
    • Pet 2: Is it an indoor or an outdoor pet?
    • Pet 2: Is your pet microchipped?*
    • Pet 2: Does your pet have any known allergies or drug reactions?*
    • Pet 2: Is your pet currently being treated for any medical conditions?*
    • Pet 2: Has this pet had any previous medical problems or issues?*
    • Pet 2: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name and personal information.*
    • Pet 3 Information 
    • Pet 3 Information

    • Pet 3: Species*
    • Pet 3: Is it an indoor or an outdoor pet?
    • Pet 3: Is your pet microchipped?*
    • Pet 3: Does your pet have any known allergies or drug reactions?*
    • Pet 3: Is your pet currently being treated for any medical conditions?*
    • Pet 3: Has this pet had any previous medical problems or issues?*
    • Pet 3: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name and personal information.*
    • Pet 4 Information 
    • Pet 4 Information

    • Pet 4: Species*
    • Pet 4: Is it an indoor or an outdoor pet?
    • Pet 4: Is your pet microchipped?*
    • Pet 4: Does your pet have any known allergies or drug reactions?*
    • Pet 4: Is your pet currently being treated for any medical conditions?*
    • Pet 4: Has this pet had any previous medical problems or issues?*
    • Pet 4: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name and personal information.*
    • SECTION: End of Pet Information 
    • Previous Veterinarian

    • Does your pet have a previous veterinarian?
    • Format: (000) 000-0000.
    • Do we have your permission to contact that veterinarian office to transfer your pet's records to our office?
    •  
    • Pet Insurance

    • Do you have pet insurance?
    • How did you hear about our practice?
    •  
    • We use client's contact information to communicate reminders, give updates, and provide directions on-site. I give Upstate Vet permission to contact me via phone call, text and email.
    • SMS message frequency from (864) 233-7650 Varies based on your interaction with Upstate Vet. Message and data rates may apply; check with your mobile carrier for applicable rates. Terms and Conditions and Privacy Policy can be found on our website at Upstatevet.com. Text us HELP for assistance or STOP to unsubscribe.

    • Resuscitation Directive

    • At Upstate Vet, your pet’s well-being is our top concern. In the unforeseen event that a life-threatening situation should arise, we need your guidance as how to proceed. We are aware that this is a highly sensitive topic, but it is extremely important that we follow your wishes. Please check one of the choices:
    • Rabies Policy for Upstate Vet

    • Is your pet current on its rabies vaccination?
    • Rabies Vaccinations:

      A pet owner must have their pet vaccinated against rabies. The rabies vaccine must be given by a licensed veterinarian.

      Reporting to DHEC (Department of Health and Environmental Control):

      All animal bites will be reported to DHEC within 48 hours. The employee that was bitten and the owner of the pet will receive a phone call from DHEC to go over information.

      Mandatory Post-bite Quarantine:

      DHEC requires any dog or cat which has bitten a person to be quarantined for a minimum of 10 days. This quarantine may be done at a veterinary clinic or at the owner’s home. If quarantined at the owner’s home the pet must be kept indoors at all times other than short leash walks. Quarantined animals may be treated by a veterinarian, but the rabies vaccine should not be administered until after the quarantine period is complete. At the end of quarantine, the pet should be reexamined by a veterinarian and the results documented.

      Rabies testing:

      Rabies can only be diagnosed by testing an animal’s brain tissue.  Unfortunately, if an animal dies or is euthanized before a 10-day quarantine period is over, the animal may need to be tested for the rabies virus. UVS and DHEC (rabies control) will be notified of the pet’s passing and will decide if the animal needs to be tested. Current rabies vaccine information is needed so that our staff can properly handle any potential rabies threat. If vaccine history is unknown please be aware of the potential steps (see above) that will be taken if your pet bites an employee while at Upstate Vet.

    • Payment Policy for Upstate Vet

    • Upstate Vet operates solely on the funds collected from the treatment and care of your pets.  We are not subsidized by any organization, private or public; therefore, we must adopt a strict payment policy in order to provide you and your pet the best possible care.  Upstate Vet does not bill or offer any type of payment plans.  For those clients that may need financial assistance to provide for their pet’s care and treatment, please ask our receptionist about the Care Credit Plan. 

      Upstate Vet requires that all fees be PAID IN FULL when service is rendered (Our Emergency Exam Fee is $220 and our Specialist Exam Fee is $265). Additional Fees will be estimated in a Treatment Plan by the Attending DVM at your request.)

      Any balance left unpaid upon completion of services will be subject to billing fees.

      I understand that failure to pick up this animal and pay all charges incurred during treatment will result in this animal being transferred to an appropriate animal shelter pursuant to State Ordinance 47-3-75 subsection a, dated May 19, 2000.  Sub-section C of said ordinance states, “A person who fails to pick up an animal provided for in subsection A, who fails to pay his boarding fees in a timely manner, or who abandons an animal at an animal hospital, a dog kennel, a cat kennel, another animal care facility, or boarding facility is guilty of a misdemeanor and upon conviction, may be imprisoned not more than thirty days or fined not more than two hundred dollars.”

       

      ScribbleVet Consent and Release:

      Our Veterinary services utilize ScribbleVet, a tool from Kairo Care Inc. Which records your pet’s appointments for improved clinical documentation. We need your consent to proceed with recording. By signing this agreement:

      1. You agree that your vet appointments may be recorded. If you do not want to be recorded, let us know

      2. You grant us permission to share these recordings, and any other materials you choose to provide, for the purpose of improved clinical documentation

      3. You affirms that you are least eighteen years old, and that you understand and accept the terms in this agreement.

       

      I, as the owner or responsible party, agree that the above information is accurate. I have also read and understand the rabies policy of Upstate Vet. I authorize Upstate Vet to administer such treatment as is necessary and is considered therapeutically and/or diagnostically necessary on the basis of findings during the course of the evaluation. I also consent to the administration of such anesthetics as are necessary. I also certify that no guarantee or assurance has been made as to the results that may be obtained. Furthermore, I assume all financial responsibility for charges incurred to the patient, consent to release of medical information, and authorize direct payment to Upstate Vet. I understand that I am liable for all collection costs, up to 100%, incurred for this account. 

      My electronic signature indicates I have read, understand, and agree to the payment agreement and the rabies policies as outlined above as well as the procedures governing them.

    • ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

       

      I, as the owner or responsible party, confirm that I am over the age of 18. Please see a Customer Service Representative if you are under the age of 18.

    • Today's Date*
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