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Emergencies Appointments

Emergencies Appointments

Request a Specialty Appointment

Client Name *

Client's Date of Birth

Required by law if your pet needs a prescription for a controlled medication.

Phone Number *

Your Email *

Address

Street Address *

City/Town

- None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province

ZIP/Postal Code

Pet's Name *

Pet's Age *

Pet's Age or DOB

Pet's Species, Breed, and Gender *

Canine or Feline?

Is Your Pet Spayed/Neutered? *

Yes

No

Referring Veterinarian's Name *

Do You Have Another Referring Vet? *

If Yes, Provide Vets Name

Requested Service *

Requested Service *

- Select -CardiologyInternal MedicineOncologySurgeryOther…

Enter other…

Reason for Appointment *

Current Medications *

Provide Medication Name, Dosage, and Quantity.

Current Diet *

Signature *

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I understand that TruVet Specialty and Emergency Hospital uses a medical AI scribe that records audio for more complete medical record documentation, and I consent to being recording in accordance with California law. *

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