Which service are you here for today? Please choose one:*Emergency ServicesSpecialty AppointmentSurgery AppointmentHave you ever been to PVESC before?* Yes No Reason for visit:When did this start?Parking Spot Number:Arrival Time:OwnerName*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (If Different): Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Cell or Home? Cell Home Secondary PhoneCell or Home? Cell Home Email Employer/OccupationCo-Owner / Authorized AgentNamePrimary PhoneCell or Home? Cell Home Secondary PhoneCell or Home? Cell Home Co-owner’s Email Address Method of PaymentMethod of PaymentCashCredit CardCare CreditScratch PayPayment Policy: Portland Veterinary Emergency and Specialty Care requires a Date of Birth and Driver’s license for all types of payments. Cash, credit cards (Visa, Mastercard, Discover and American Express), Care Credit and Scratch Pay are acceptable forms of payment. No personal, third party, or business checks are accepted.Owner Date of Birth:Owner’s Driver License #/State:Pet InformationPet's Name:Dog / Cat / OtherDogCatOtherOtherBreedColorDate of Birth/Age:SexMaleFemaleMale / Neutered Yes No Female / Spayed Yes No Vaccine HistoryRabiesUp to dateNot up to dateDistemperUp to dateNot up to dateLymeUp to dateNot up to dateLeptoUp to dateNot up to dateLeukemiaUp to dateNot up to dateList of ongoing health conditions:List of Pet's Medications:Regular Veterinary Clinic***Your pet may be photographed while in our care. May we use your pet’s photo on our website or Facebook page?* Yes No ***How did you hear about us?* Family Veterinarian Google Listing Facebook Word of Mouth News Paper or Magazine Ad Movie Theater Ad Authorization: I (owner or authorized agent for the owner) hereby authorize Portland Veterinary Emergency and Specialty Care veterinarians and staff to examine, prescribe for, and treat the pet described above. Further I understand: That no guarantee of successful treatment is either made or implied. No assurance or guarantee has been made of the results of sedation, anesthesia, surgery and/or treatment and the probabilities of complications exist in any sedation, anesthesia, surgery and/or medical treatment. I assume full responsibility for all charges incurred in the care of said animal and understand all fees must be paid in full upon completion of services and prior to discharge of the animal from Portland Veterinary Emergency and Specialty Care. Should said animal have to be hospitalized or should a surgical procedure be performed, a deposit amounting to 50% of the high end of the estimated fees is required for ALL surgeries and hospitalized patients. Radioactive Iodine Therapy requires payment in full prior to admission. PVESC reserves the right to treat any pet presented with fleas with an oral medication to treat the immediate situation. There is a charge for this treatment. Please Note: If for any reason you are unable to pay your account in full and your account is sent to collection, PVESC reserves the right to add 50% of the balance due to your account to cover collection costs.Owner Signature:*Date MM slash DD slash YYYY Co-Owner / Authorized Agent Signature:Date MM slash DD slash YYYY Information provided is for Portland Veterinary Emergency and Specialty Care use only. No information is disclosed, sold or given to 3rd partiesIf you are here for an emergency, please call our office after you submit this form and have secured your parking spot. 207-878-3121PhoneThis field is for validation purposes and should be left unchanged. Δ