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Arrival Check-in
(773) 478-0631
CHESHIRE PARTNERS + VHMA
Digital Client Center
Client Arrival Check-In
Client Survey
Drop Off Questionnaire for Sick Pet
Heartworm Treatment Release Form
New Patient Form
Pay Online
Prescription Refill
Well Pet Drop Off Form
Surgery / Dental Drop Off Form
Event Booking System
Lectures
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Staff Directory
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Menu
Digital Client Center
Client Arrival Check-In
Client Survey
Drop Off Questionnaire for Sick Pet
Heartworm Treatment Release Form
New Patient Form
Pay Online
Prescription Refill
Well Pet Drop Off Form
Surgery / Dental Drop Off Form
Event Booking System
Lectures
My Bookings
Locations
Team Portal
Documents & Forms
Staff Directory
Announcements
E-commerce
Portfolio
Contact
Surgery / Dental Drop Off Form
All required fields are marked {*}
Client Information
Client Name:
First
Last
Today's Date:
Month
Day
Year
Client Email:
Patient Name:
Color:
Sex:
Male
Female
Age:
Breed:
I authorize the performance of the following procedure(s):
Has your pet had anything to eat or drink today?
Yes
No
If "Yes" above please explain:
Has your pet had any medications in the last 24 hours (including non-prescription medication or supplements)?
Yes
No
If "Yes" above please explain:
Is your pet currently on a special diet (including treats)?
Yes
No
If "Yes" above please explain:
Please list any vaccinations your pet is currently due for: (If they are up to date please say None)
All patients are required to be current on Rabies immunization. Proof required upon check-in.
I Understand
Any patients not meeting these requirements will be treated at the owner’s expense ($18).
I Understand and Accept
I understand sedation may be required for the patient to relax during the procedure for the ultrasound to be performed.I authorize the use of sedation if necessary, which will be an additional charge. I understand that while the sedation used in this hospital is one of the safest used in veterinary medicine, NO sedation is without medical risks. No guarantee can be made legally or ethically to me on the outcome of any procedure performed. Any complications that may arise from the above procedure(s) may incur additional charges.
0-25 pounds - $60.00 26-50 pounds - $80.00 51-100 pounds - $100.00 >100 pounds - $130.00
Name
First
Last
Signature
Phone number where you can be reached TODAY (Very Important)
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Name
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