Patient Intake Form

Owner Information


Pet's Information

If known: Please list all vaccines and last date given.
Please list what type of food given, how many times fed each day, and approximately how much each day.
Type of treats and how often/how many
Actively on Heartworm Preventives?
Actively on Flea/Tick Preventives?


We will gladly provide you with a written estimate if you desire – just ask the doctor or technician. We accept, cash, check, debit card(VISA, MASTERCARD, DISCOVER), or Carecredit. There will be a service fee of $35.00 for all returned checks.
  • I give my permission to examine and treat my animal and assume all responsibility for all charges incurred in the care of my animals and/or any animal that I may seek care for with Emerald City Animal Hospital.
  • By completing this form, you are giving us consent to use automated or predictive dialers to contact you on all numbers provided, including cell phones, concerning any unpaid or remaining balance on your account. This does include any outside collection agency if your account is assigned to collections due to nonpayment.


  • By South Carolina Law, prescription medications cannot be returned. It’s difficult to guarantee the integrity of a drug after it has left our office.
  • Any other items you wish to return must be done so within 14 days. Please make sure they are in the original sealed package, unopened, except for food. We will not take any opened cans of food back.
To honor online order requests, we must have a doctor and patient relationship established and the pet must have ab exam by the vet within the last 12 months. We must have a current heartworm test on file to fill heartworm medicine request.If you’ve ever searched online for prescription pet medicines, you’ve likely seen similar eye-catching, attention-grabbing claims. They sound convincing, promising convenience and lower prices, but are these claims always true?Many online pet pharmacies are reputable. Some, however, may be businesses breaking Federal, State, and sometimes, International laws. These illegal online pharmacies may sell medicines that are counterfeit, outdated, mislabeled, or incorrectly formulated. The medicines may not contain the actual drug or may contain incorrect amounts of drug. Some may not work as well if the product is old(expired) or has been stored in conditions that were too hot, cold, or humid. Others may not have the proper directions for use. If you are unhappy with the products you ordered, you may not be able to get your money back from illegal online pharmacies.At Emerald City Animal Hospital, we pride ourselves on offering the highest quality of medicine. To do so, we source all our medicines directly from the companies that produce these medications, or through distributors that have a direct relationship with the supplier. ALL OF OUR PRODUCTS CARRY THE MANUFACTURER'S GUARANTEE.However, many online pharmacies that offer discounted rates on prescription products such as flea, tick, and heartworm preventatives DO NOT carry the guarantee. Often, these guarantees give you assistance should your pet become heartworm positive or sick.WE WILL NOT BE ABLE TO PROVIDE ASSISTANCE SHOULD YOU SUSPECT YOUR PET BECAME SICK FROM A PRODUCT NOT PURCHASED THROUGH US OR OUR DIRECT ONLINE PHARMACY! YOU WILL NEED TO GO THROUGH THE ONLINE PHARMACY YOU USED, AND IF THEY ARE NOT APPROVED TO DISTRIBUTE THAT PRODUCT, THE MANUFACTURER WILL NOT BE ABLE TO PROVIDE ASSISTANCE TO YOU EITHER.If you should choose to not purchase medications through our hospital, we do not recommend ever purchasing products that are coming from a NON-accredited online pharmacy OUTSIDE the United States. There are many online stores that sell products that look like the real thing, but they are not and may contain harmful chemicals.PLEASE SIGN BELOW SO THAT WE KNOW THAT YOU ARE AWARE OF THE RISKS YOU ARE TAKING BY PURCHASING MEDICINES FROM AN ONLINE PHARMACY