Owner Name(s): First and Last Name Phone Number: Additional Phone Number: Address: City, State: Salem, OR Keizer, OR Aumsville, OR Dallas, OR Independence, OR Lincoln City, OR McMinnville, OR Monmouth, OR Silverton, OR Stayton, OR Turner, OR Woodburn, OR Other - input below If your City/State was NOT listed, please input here: Zip Code: Email Address: Have you or anyone close to you been in contact with someone who has tested positive for COVID-19 within the last month? Do you or anyone with you today have a recent history of respiratory illness? Pet's Name: Pet's Species: Cat Dog Bird Rabbit Reptile Other Pet's Breed: Pet's Color: Pet's Age: Pet is: Male Male / Neutered Female Female / Spayed Male / Unknown Female / Unknown Unknown Sex Pet's Primary Care Veterinary Clinic: Is your pet current on vaccinations? Pet's Current Diet or Brand of Food: Please describe the reason for your pet's emergency or urgent care visit today.
Check any symptoms your pet is experiencing or has experienced recently:
When did these symptoms start? Or when did the incident happen? Any previous medical issues or diagnosed conditions? Any recent changes in your pet's diet or environment? Has your pet had reactions to vaccines or medications? Any known allergies or food sensitivities? Is your pet currently taking medications (including supplements, vitamins, flea products, etc.)? Include dosage, how often medication is given, or last time dose was given. My pet is transferring from another veterinary hospital:
Our clinic works on a system of triage and critical patients will be rushed into our hospital as quickly as possible. If your pet is currently stable, would you prefer to:
I am parked in: Emergency Clinic Parking #1 Emergency Clinic Parking #2 Emergency Clinic Parking #3 Emergency Clinic Parking #4 Emergency Clinic Parking #5 Near Salem Pet Supply Near SOAR (Animal Rehab Clinic) Elsewhere in the Parking Lot I am on the way Color/Make/Model of your Vehicle: Send