Veterinary Specialty Care - New Patient Form

Date:*

2012-02-23

Owner:*

Co-Owner:*

Address:*

City:*

State:*

Zip:*

Home Phone:*

Cell Phone:*

Other Phone:*

Referring Vet:*

Hospital:*

Pet's Name:*

Sex:* Male Female

Spayed/Nutered:* Yes No

Pet's Breed:*

Pet's Color:*

Pet's Age:*

How long has your pet lived with you?:*

Other pets?:*

Is your pet on any medications?:* Yes No

Does your pet have any allergies?:* Yes No

List Medications:*

Is your pet current on vaccines?:* Yes No

Heartworm Prevention?:* Yes No

Flea Control?:* Yes No

Any Recent Diagonstics?:* Yes No

Xrays?:* Yes No

Bloodwork?:* Yes No

Biopsy?:* Yes No

Reason for visit?:*

Previous Health Problems?:*

Payment Policy and Treatment Consent* Yes

BY CHECKING ABOVE I UNDERSTAND AND AGREE TO: AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND PROVIDE INITIAL DIAGNOSTICS FOR MY PET. I AM AWARE A DEPOSIT MAY BE REQUIRED PRIOR TO WORK UP. I AM 18 YEARS OLD OR OLDER AND AM ACCEPTING FINANCIAL RESPONSIBILITY FOR THIS PATIENT. ASSUME FINANCIAL RESPONSIBILITY FOR ALL HOSPITAL CHARGES. ASSUME RESPONSIBILITY FOR ALL FEES ASSOCIATED WITH THE COLLECTION OF ANY UNPAID BALANCES INCLUDING $25.00 FOR RETURNED CHECKS. THE BALANCE WILL BE PAID IN FULL AT THE TIME OF DISCHARGE.

I give Veterinary Specialty Care permission to use any photograph taken of my pet while hospitalized at our facility for our website, networking sites etc.

Method of Payment:*
Cash Check Visa MasterCard Discover Debit Care Credit

Security Question:

What does 1 + 3 equal?

Veterinary Care Specialists

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Medical Care

Surgical Care

Emergency Care

Advanced Imaging

New Patient Form

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