Open 24 hours 7 days a week

5818 Maplecrest Road
Fort Wayne, IN 46835

P: (260) 426-1062

F: (260) 485-0130

View Northeast Indiana Veterinary Emergency & Specialty Hospital Map
Northwest Indiana Veterinary Emergency Specialty Hospital

Registration Form

Please contact our office at (260) 426-1062 to schedule your pet's appointment prior to completing the online registration form. You can also download and print our PDF version - Download Registration Form PDF Version


[*] Please fill out required fields

Preliminary Information

Date Form Filled Out[*]


Have you ever received care at this office before? Yes No
Date of last visit

Owner Information

Owner(s) Name[*]
Home Address [*]
City/State [*]
Zip Code[*]


Home Phone[*]
Cell Phone [*]
Work Phone


Owner(s) Email[*]
Spouse Cell Phone
Drivers License Number (required unless paying by cash):


Employer
Spouse or Partner Name
Referring Veterinarian [*]
Primary Care Veterinarian**


**If you do not currently have a primary care veterinarian for your pet, please state "NONE"**

Patient Information

Patient Name [*]
What's your pet's species?[*] Dog Cat Other


If other, what species?


Breed
Color
Age [*]
Sex[*]


Is your pet neutered? Yes No


Date of birth
Date of last vaccines[*]


Previous medical history/surgeries: [*]
Reason for visit: [*]

Payment Method

Payment Method Cash Check Mastercard Visa Discover American Express Care Credit

I hereby authorize Northeast Indiana Veterinary Emergency and Specialty Hospital, to administer needed medical and/or surgical treatment. I authorize the attending doctor and assistants to handle and treat the patient as necessary, to ensure safety for all during the evaluation. I further understand that an estimate may be provided for medical/surgical expenses but verbal consent can be obtained for treatment. I assume financial responsibility for all treatment and realize that direct payment is due at the time of service. Should payment method fail and collection efforts become necessary signer will be held responsible for costs of collection and/or attorney fee.

Signature: (Entering your name here will be your digital signature:) [*]
Email Address [*]


Must be at least 18 years or older to authorize treatment.







Pet Owners

Refer a Patient

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Our Location

5818 Maplecrest Road

Fort Wayne, IN 46835

P: (260) 426-1062

F: (260) 485-0130

News & Events

Expanding Role of Nutrition in the Diagnosis and Management of Gastrointestinal Disorders

November 14, 2017

Topic: Expanding Role of Nutrition in the Diagnosis and Management of Gastrointestinal Disorders

Speaker: Veronica L. Whiteside, DVM

Location: NIVES Conference Room, 5818 Maplecres ...[READ MORE]

ALL UPCOMING EDUCATION EVENTS →


NIVES is Certified as a Level II Critical Care Facility

Northeast Indiana Veterinary Emergency & Specialty Hospital © 2016 - 2017
5818 Maplecrest Road, Fort Wayne, IN 46835
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Pet Emergency Hospital Serving Fort Wayne, Indiana, Ohio and Michigan.Bring your pet to our emergency animal hospital if having a pet emergency.