Preregistration Form

Please fill in the form below and click the Submit button.

fields marked with * are required and must be included in order to submit the form.

    Client Information

    Pet Information

    Additional Pet Information

    CPR (Cardiopulmonaruy Resuscitation)/DNR (Do Not Resuscitate)

    To allow for optimal treatment of your pet(s), all patients hospitalized at Animal Emergency & Specialty Center (AESC) are assigned a CPR code. This code enables AESC to carry out your wishes if it should become necessary during or following an emergency. CPR can add $150 to the final invoice price.

    If it becomes necessary during your pet’s visit/stay, would you like us to administer CPR?

    Financial Information

    In the event that I am unreachable, I hereby authorize Animal Emergency & Specialty Center (AESC) to do what is necessary to stabilize my pet in an emergency situation. These measures may include (but are not limited to): Radiographs (X-rays), laboratory testing, and injection or pain medication administrations. These initial diagnostic/treatment measures may cost $250-$500. I understand that further testing may be necessary. A thorough exam will be performed by the staff veterinarian. Once you are reached by telephone, you and the veterinarian will create a comprehensive treatment plan for your pet, and an estimate will be prepared. You will be responsible for any charges incurred at the time of service.