Jaime Nalezny, D.V.M.

Avian & Exotic Veterinary Housecall Service, PLLC

612/520-1386

PATIENT/CLIENT/BILLING PARTY INFORMATIONYour Name/Title:
Address:

City:

Email:

Zip:

Employer:Home Phone #:Work Phone #:How do you prefer to be notified of reminders?

Employer Phone #:Phone message

Text

Email

SPOUSE OR SIGNIFICANT OTHER INFORMATION
Name/Title:
Email:

Employer:Home Phone #:Work Phone #:Employer Phone #:EMERGENCY CONTACT INFO
Who to contact:@ Telephone:

BILLING & RESPONSIBILITIESParty responsible for all care decisions:Party responsible for all financial decisions:(if paying by check) Driver’s License #:State:OTHER
How did you first learn of our hospital?

We would like to thank any individual who referred you.

AAV/ARAV/AEMV ReferralWebsite:

Other:

Referred by:
AT YOUR REQUEST WE WILL GLADLY DISCUSS COST OF SERVICES
AND/OR PREPARE A WRITTEN ESTIMATE FOR RECOMMENDED PROCEDURES.

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
DEPOSITS MAY BE REQUIRED FOR PETS BEING ADMITTED.

We accept cash, checks drawn from a local bank, credit cards or payments thorough PayPal to vet@aevhs.com.
We charge a $50 fee for any returned checks and a 50% cancellation fee of the cost of the exam if you cancel
within 24 hours of the appointment. New clients are required to have a credit card deposit. We are happy toapply this amount toward a future rescheduled appointment in the event of a cancellation.
I, the undersigned and owner of the following pet(s):have had explained to me the recommended procedures along with the risks and elect to have Dr. Jaime Nalezny ofAEVHS proceed with examinations for these pet(s) of mine and the elected procedures of:I understand that all pets that I wish to have groomed are required to have an examination to assess them for anyrisks prior to elective procedures. If my pet is not found to be healthy at the time of the exam, Dr. Jaime Nalezny andAEVHS may elect to forgo the procedure until my pet is healthier and more stable. Furthermore, I agree to not holdDr. Jaime Nalezny or AEVHS, PLLC liable for any unforeseen circumstances when handling my pet, providing
treatment, or observing any of the following animals on the next page(s) for veterinary treatment and care.

SIGNATURE of decision-maker

DATE

SIGNATURE of financial decision-maker** if different from above

DATE

Please continue on the next pageJaime Nalezny, D.V.M.

Avian & Exotic Veterinary Housecall Service, PLLC

612/520-1386

PATIENT/CLIENT INFORMATION

PET # 1

PET # 2NameSpecies
Breed
Description/Color
Age
Hatchdate/Date of Birth
Sex/Altered?
Length of Time Owned
How Obtained?
Previous Hospital/VetMicrochip #Previous testing:
CBCChemistryFecal
Fecal gram stain
Chlamydia PCR

Please continue on the next page

PET # 3

Jaime Nalezny, D.V.M.

Avian & Exotic Veterinary Housecall Service, PLLC

612/520-1386

Any Other tests?
Pet sitter
Boarding facility
Current Medications
Special Diet
Prior Illness/Accidents
Prior Surgery

DETAILS*please include any concerns you have with your pet, including any problems encountered at previous veterinary examinations*Symptoms of Coronavirus (COVID-19)
Your symptoms can include the following:Fever

If you have COVID-19,
you may have mild (or nosymptoms) to severe illness.
Symptoms can appear
2-14 days after you areexposed to the virus thatcauses COVID-19.
Seek medical attention
immediately if you or someone
you love has emergency
warning signs, including:

Cough• Trouble breathing• Persistent pain or pressurein the chest

Shortness*Symptoms mayof breath appear 2-14 days

• New confusion or not able tobe woken• Bluish lips or faceafter exposure.

This list is not all inclusive. Please consult your
medical provider for any other symptoms thatare severe or concerning.

cdc.gov/coronavirus
CS 316475-A April 13, 2020 6:49 PM

Avian & Exotic Veterinary Housecall Service, PLLC
p: 612/520-1DVM | f: 800/975-1624 | scheduling@aevhs.com
COVID-19 pandemic emergency veterinary treatment notice and acknowledgement of risk form
Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This
document provides information we ask you to acknowledge and understand regarding the COVID -19 virus.
The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic.
You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks ofcontracting COVID -19 while having your pet seen by us for care.
The COVID-19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms
and yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicated due to limited
availability of virus testing.
Due to the frequency and timing of visits by other clients with patients, the characteristics of the virus, and the characteristics
of certain procedures, there is an elevated risk of you contracting the virus simply by being in an enclosed room, vehicle, oroffice with others. Therefore we are only seeing patients in our vehicle for short periods of time, and allowing “curbside” drop off
appointments with transition of patients into disinfected carriers for transport into our office or RV for treatment; or as season,
weather and species and patients permit, an outdoor visit for care. Reasons we must physically see patients include but are notlimited to: the establishment of a legal and valid veterinary-client-patient relationship prior to instituting telemedicine, collectingsamples, administering treatment, or to physically care for a patient during the COVID-19 pandemic.
Pursuant to statements and orders from the Center for Disease Control (CDC), the American Veterinary Medical Association(AVMA) and Governor Walz, elective, emergency and urgent treatment may be rendered based on the professional judgement ofhealth care professionals.

By signing this document, I confirm that:I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID-19 virus byentering within the veterinary office, interacting with staff members, or with the treatment of my pet. I further confirm that I am
seeking treatment for a condition that meets the criteria noted above and that I have not recently tested positive for Covid-19 oram I experiencing any symptoms of Covid-19 at this time. I understand and accept the additional risk of contracting COVID-19
from contact by interacting with the staff of AEVHS, or bringing my pet to the AEVHS office. I understand that I must wear amask and will review the read me file for current policies and procedures. I acknowledge that I could contract the COVID-19 virus
outside of the AEVHS office or staff of AEVHS in circumstances unrelated to my visit here.
You understand that the benefits of having your pet: Your pet's name here
include the benefits of:seen for, i.e. an exam for illness, well check

Please enter what benefits this visit may have (i.e. establishing care, diagnosis/treatment of illness, mitigation of suffering)I have read and understand the information stated above, and also that scheduled procedures may be canceled withvery short notice should a client, staff member, or patient test positive for, or experience signs or symptoms of,
COVIDand believethesebenefits
outweighrisk of contracting
19,
the facility's
healthcare
capacitychange,theor COVID-19
caseloadsCOVID-19.
in the community change or the veterinary
community is ordered by executive order to change our operations.

Signature

Date

Avian & Exotic Veterinary Housecall Service, PLLC
p: 612/520-1DVM | f: 800/975-1624 | scheduling@aevhs.com
COVID-19 Client Disclosures
This client disclosure form seeks information from you that we must consider before making treatment decisions in thecircumstance of the COVID-19 virus. Please fill this out the NIGHT BEFORE OR MORNING OF of your appointment.
A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer
treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk
for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understandthat we may ask you to consider rescheduling your pet’s appointment or we may need to take extra precautions to see
your pet after discussing any such conditions with us. We reserve the right to cancel appointments at any time.
It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you
have experienced any signs or symptoms associated with the COVID-19 virus. Please enter any possible exposures
below, and the nature of these exposures in the last 14 days:
If no concerns for exposures, please enter "n/a"Do you have a fever or above normal temperature?
Have you experienced shortness of breath or had trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell?
Do you have a sore throat?
Have you been in contact with someone who has tested positive for COVID-19?

Have you tested positive for COVID-19?
Have you been tested for COVID-19 and are awaiting results?

yes
yes
yes
yes
yes
yes
yes
yes
yesHave you traveled outside the United States by air or cruise ship in the past 14days?

yes

Have you traveled within the United States by air, bus or train within the past 14
days?

yes

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune
system and have disclosed to my provider any conditions in my health history which may result in a compromised
immune system.
By signing this document, I acknowledge that the answers I have provided above are true and accurate.

___________________________________________________________________ ___________________
Signature
Date

Avian & Exotic Veterinary Housecall Service, PLLC
Jaime Nalezny, D.V.M. | p: 612/520-1DVM | f: 800/975-1624 | vet@aevhs.com
FISH HISTORY INFORMATION

1)
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3)
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Your fish’s name:Your fish’s species:
Your fish’s sex:
Freshwater or marine?
Where did you obtain your fish?
a. How old was your fish when s/he was obtained?
b. Do you believe you know your fish’s current age?
c. How long have you had your fish?
Systema. size in gallons:b. Species in the system (all tanks sharing a common filter) affected:
c. Species not affected:
d. Any new intros to the tank, and if so- what species and when:e. Number of fish in system
f. Average fish size in grams, cm:
g. Does your fish share a home with any other fish or other animals? If so, what species? If there are otheranimals in the home that are not within the aquaria, please list these as well and please describe any
interactions allowed:
How long has your tank been set up
a. What is the temperatureb. What do you have to support life in the enclosure (i.e. filtration, oxygen, chillers, etc.)
What foods does your fish eat:a. Trade/brand or Commercial names of prepared foods:
b. Supplements:c. Fresh foods (please state type of food i.e. raspberries, not just “fruit”):
Do you provide any lighting or access to unfiltered sunlight outdoors in the summer?
Water sourcea. Plumbing- metal or plastic or both?
b. Water appearance grossly (cloudy? Colored? Clear?)c. History of water changes, routine maintenance, water quality testing and results historically (attach sheets ifneeded)
Water quality testing:a. Dissolved oxygen in mg/L
b. Temp:c. pH:
d. Ammonia in mg/L:
e. Nitrite in mg/L:
f. Chloride in mg/L:
g. Nitrate in mg/L:
h. Hardness in mg/L:
i. Alkalinity in mg/L:
j. Salinity in ppt:
k. Please bring us current water samples
Illnessa. Has your fish had any previous illnesses? If yes, please explain.
b. Any behavior changes noted along with concerns? If so, what?
c. When did your fish first show signs of illness?
d. When did the last fish show signs of illness?
e. Gill movement rate (normal/fast/slower)?
f. Appearance of the fish?

Please List Individual Pet Information On The Back Of This Form

Avian & Exotic Veterinary Housecall Service, PLLC
Jaime Nalezny, D.V.M. | p: 612/520-1DVM | f: 800/975-1624 | vet@aevhs.com
FISH HISTORY INFORMATION
g.
h.
i.
.

13)

14)

Appetite of the affected fish?
Any other clinical signs?
i an ish die after developing any concerns, when was the 1st loss?
o e than one ish ie , how an iewhen did the last fish die?
i. If a fish has died, have you preserved the fish? How, and for howlong?
ii. If veterinary
a fish has previously
passedwas havea necropsy
performed?
What previous
care has s/hehad?away
Pleaseany records
faxed over to us at 800-975-1624 for our
review prior to the appointment if any.
a. What, if any, diseases has your fish been tested for?
b. Has your fish ever lived with any other fish, even at the last home or store?
i. If so, have you had him/her tested for any diseases since?
Do you have any additional concerns regarding your fish or system?