We understand that your primary concern is bringing your sick or injured pet to us as quickly and safely as possible so we can promptly diagnose them and begin treatment. This form will help us to learn more about you and your pet and facilitate their care plan. Please complete this form while you are here. We are happy to answer any questions.

ecaemergency.com

252.580.2032

info@ecaemergency.com

101 Commercial Boulevard, Suite B

Elizabeth City, North Carolina 27907

Pet Owner Information*

Name* *

Address* *

Owner Date of Birth* *

YYYY

Phone* *

(###)

###

####

Email *

Veterinarian Information

Primary Care Hospital/Veterinarian* *

Pet Information

Reason for Visit *

Name *

Date of Birth* *

YYYY

Species*

Dog

Cat

Other

Sex* *

Female

Spayed Female

Male

Neutered Male

Breed* *

Color/Markings

Rabies Vaccine*

Up To Date

Not Given/Expired/ Unknown

Date Given

YYYY

Known Allergies to Medications*

Do You Have Pet Insurance?

Yes

If Yes, Who Is Your Carrier?

24/hr Pet Watch

ASPCA

Embrace

Trupanion

Other

If Yes, What is the Policy Number?

CPR is an emergency medical procedure used when a pet experiences cardiac and/or respiratory arrest. It includes external chest compressions, ventilation through intubation, and the administration of medications to restart the heart and breathing. The procedure aims to restore spontaneous circulation and breathing. While CPR can be critical in saving a pet's life, it is essential to understand that it can be costly and has a success rate of 6-7% for acute arrest, or 50% if a pet is under general anesthesia.

If my pet experiences cardiac or respiratory arrest,

Yes I authorize immediate basic life support interventions.

No, I do not authorize immediate basic life support interventions.

I hereby authorize ECAE to examine, prescribe for, and/or treat the above pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required. I also hereby grant permission to ECAE to use my pet’s photos, radiographs, ultrasound, medical data, and other treatment-related information for research, presentation, and education.

Digital Signature of Owner*

I Am 18 Years of Age or Older*

Date

YYYY

I Read and Agree*

*Fields marked with an* are required.

PLEASE NOTE THAT PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED.

We accept Visa, MasterCard, American Express, Discover, CareCredit, ScratchPay, Cash and Check

Thank you!

ecaemergency.com
info@ecaemergency.com
252.580.2032
101 Commercial Boulevard, Suite B
Elizabeth City, North Carolina 27909

HOURS

Open Wednesday - Sunday 8 pm to 8 am

    Closed Monday & Tuesday

PET OWNERS
Click here for a new patient form

VETERINARIANS
Click here for a referral form

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