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323-800-VETS (8387)
About Us
Our Mission
Veterinarians
Emergency & Critical Care
Rehabilitation/Integrative Medicine
Doctors
Physical Therapist
Internal Medicine
Cardiology
Neurology and Neurosurgery
Surgery
Services
Emergency Medicine
Critical Care
Neurology and Neurosurgery
Surgery
Internal Medicine
Cardiology
Rehabilitation/Integrative Medicine
For Pet Owners
Client Registration
General Information
Online Pharmacy
Pet Parent Portal
Resources
Code of Conduct
Payments
For Veterinarians
Published Works
RACE Approved Continuing Education Events
Referrals to LAASER
Let’s Stay Connected!
Careers
Contact Us
Client Registration Form
Online Pharmacy
323-800-VETS (8387)
About Us
Our Mission
Veterinarians
Emergency & Critical Care
Rehabilitation/Integrative Medicine
Doctors
Physical Therapist
Internal Medicine
Cardiology
Neurology and Neurosurgery
Surgery
Services
Emergency Medicine
Critical Care
Neurology and Neurosurgery
Surgery
Internal Medicine
Cardiology
Rehabilitation/Integrative Medicine
For Pet Owners
Client Registration
General Information
Online Pharmacy
Pet Parent Portal
Resources
Code of Conduct
Payments
For Veterinarians
Published Works
RACE Approved Continuing Education Events
Referrals to LAASER
Let’s Stay Connected!
Careers
Contact Us
Client Registration Form
Online Pharmacy
EMERGENCY 24/7 SUPPORT
323-800-VETS (8387)
Call Now
Instagram
Linkedin
323-800-VETS (8387)
About Us
Our Mission
Veterinarians
Emergency & Critical Care
Rehabilitation/Integrative Medicine
Doctors
Physical Therapist
Internal Medicine
Cardiology
Neurology and Neurosurgery
Surgery
Services
Emergency Medicine
Critical Care
Neurology and Neurosurgery
Surgery
Internal Medicine
Cardiology
Rehabilitation/Integrative Medicine
For Pet Owners
Client Registration
General Information
Online Pharmacy
Pet Parent Portal
Resources
Code of Conduct
Payments
For Veterinarians
Published Works
RACE Approved Continuing Education Events
Referrals to LAASER
Let’s Stay Connected!
Careers
Contact Us
Client Registration Form
Online Pharmacy
323-800-VETS (8387)
About Us
Our Mission
Veterinarians
Emergency & Critical Care
Rehabilitation/Integrative Medicine
Doctors
Physical Therapist
Internal Medicine
Cardiology
Neurology and Neurosurgery
Surgery
Services
Emergency Medicine
Critical Care
Neurology and Neurosurgery
Surgery
Internal Medicine
Cardiology
Rehabilitation/Integrative Medicine
For Pet Owners
Client Registration
General Information
Online Pharmacy
Pet Parent Portal
Resources
Code of Conduct
Payments
For Veterinarians
Published Works
RACE Approved Continuing Education Events
Referrals to LAASER
Let’s Stay Connected!
Careers
Contact Us
Client Registration Form
Online Pharmacy
EMERGENCY 24/7 SUPPORT
323-800-VETS (8387)
Call Now
Client Registration Form
Client Information Section
Are you having a critical emergency with your pet?
(Required)
Yes
No
Please call our office at 323-800-VETS (8387) for assistance
Are you over the age of 18?
(Required)
Yes
No
You must be 18 years of age or older to complete this form. Please call our office for further assistance.
What is your first and last name?
(Required)
What is your current location (in relation to LAASER)
(Required)
Arrived at hospital- waiting in car
At home
En route
What is your street address? (incl unit/apartment number)
(Required)
What city do you live in?
(Required)
What state do you live in?
(Required)
What is your zip code?
(Required)
What is the best phone # to contact you at?
(Required)
type of phone
(Required)
Mobile
Personal home
Work
Please provide an additional phone number in case of emergency:
(Required)
Untitled
(Required)
Mobile
Personal home
Work
Much of our communication is done via email, please provide a valid email address:
(Required)
How did you hear about us? (If you were referred by your primary care veterinarian, or a current client, please tell us their name in the "Other" section).
Google search
Other web search
Facebook page
Instagram
Recommended by friend/family/colleague
Referral from primary care veterinarian
Other
Patient Information
What is your pet's name?
(Required)
What is your pet's current age? ( in years and/or months or weeks)
(Required)
What is your pet's species?
(Required)
Canine
Feline
Other
What is your pet's breed?
(Required)
What is your pet's color of fur?
(Required)
What is your pet's sex?
(Required)
Male-Intact
Female-Intact
Male-Neutered
Female-Spayed
Do you have a primary care veterinarian/hospital/clinic you have been to in the last 3 years? Yes/No
(Required)
Yes
No
What is the name of your primary veterinary hospital/clinic you take your pet to?
(Required)
At above veterinary practice, do you see a particular doctor? If yes, please enter their name here:
(Required)
General History Section
What is the reason for your visit with your pet today?
(Required)
How long have the above symptoms been occurring?
(Required)
When did your pet last receive vaccinations (including rabies and parvo/distemper for dogs and rabies and feline FVRCP for cats)
(Required)
Less than 1 year ago
1-3 years
Greater than 3 years
My pet has never been vaccinated
What type of food does your pet normally get fed?
(Required)
Over-the-counter regular dog/cat food (Friskies, Alpo, etc)
Special prescription food from the veterinarian
Raw diet
Home cooked food
Other
If prescription food, which brand/food type?
When did your pet last eat (approximate hours ago)
(Required)
Does your pet have any allergies (to anything including food or medication). If so, please list them here. If not, please skip.
Have you travelled with your pet out of Southern California within the last 3 months?
(Required)
Yes
No
If yes, where:
Did you adopt/obtain/purchase your pet from somewhere in Southern California?
(Required)
Yes
No
If no, what state/country did your pet originate from?
Do you have other pets in your home?
(Required)
Yes
No
If yes, please list the other species (and how many) you have:
Where does your pet primarily reside?
(Required)
Indoor only- strictly, other than walks
Outdoor only- rarely comes inside
Indoor/outdoor- spends some or most of the day outside, comes in at night.
Other
Covid Questionaire
Have you had contact with anyone with confirmed COVID-19 in the last 14 days?
(Required)
Yes
No
Are you exhibiting any of the following symptoms? a. Fever over 100 F b. Cough c. Difficulty breathing
(Required)
Yes
No
Within the last 14 days, have you exhibited any of the following symptoms? a. Fever over 100 F b. Cough c. Difficulty breathing
(Required)
Yes
No
Payment and Consent Section
By checking each item and signing below below, I acknowledge that:
Untitled
(Required)
The information indicated above is correct.
(Required)
Untitled
(Required)
I understand that payment is due at the time of service with cash, Visa, Mastercard, Discover, Debit Card, American Express, or third-party financing.
(Required)
Consent
(Required)
I am the owner or authorized agent of the above described animal and assume financial responsibility for the consultation fee and any additional services performed.
(Required)
Consent
(Required)
Final charges are based on services provided not based on results or diagnosis.
(Required)
Consent
(Required)
I authorize the release of information to the veterinary hospital indicated above and to veterinarians, financial institutions, and insurance providers requesting records and information pertaining to the care received here.
(Required)
Consent
(Required)
If any amounts due are not paid at discharge, I understand that LAASER shall commence collection efforts against me immediately. In addition to the amount due at discharge, I will be responsible for the cost of collection (including, without limitation, attorney fees, filing fees and court costs) and interest at a rate of 6% per annum.
(Required)
Print Name:
(Required)
Signature
(Required)
Date
(Required)
Month
Day
Year
