PVRE Registration Form

REGISTRATION FORM
Client Information (Pet Owner)
Primary Account Holder *

First NameLast Name
Phone Number*

Area CodePhone Number
Phone Type*

CellHomeOther
Alternative Number

Area CodePhone Number
Phone Type*

CellHomeOther
Drivers License Number/State Issued ID *
State issued from:
Address*

HOME ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE
OCCUPATION*
Email*
example@example.com
Secondary Contact

First NameLast Name
Relationship

SpouseRelativeFriendOther
Phone Number

Area CodePhone Number
Phone Type

CellHomeOther
Primary Veterinarian Information
PRIMARY VETERINARY CLINIC*
CROSS STREETS *
of your Primary Veterinarian
PRIMARY DOCTOR
Patient (Pet) Information
NAME*
Sex*

MaleMale NeuteredFemaleFemale Spayed
DOB or AGE*
Age is listed in *
Species*

Canine (dog)Feline (cat)Other
BREED*
COLOR*
HOW LONG HAVE YOU HAD YOUR PET?*
Has your pet ever shown aggression toward people or other animals?

YesNo
If your pet has previously shown aggression please explain.
What brand brand of food do you feed your pet? *
Has your pet had vaccinations in the last year?*

YesNoUnsure
Date of last rabies vaccination, if known

MonthDayYear
Date
Is it okay to use photos of your pet on our social media? *No personal information will be released*

YesNoUnsure at this time
Are you interested in applying for Care Credit (a third party payment plan for you veterinary expenses?*

YesNoUnsure at this time
Advance Directive:
Type a question*

CPR: I authorize the veterinary healthcare team to attempt CPR on my pet. These efforts may include placement of an IV catheter, chest compressions, placement of a breathing tube and emergency drug administration. I understand that the costs for CPR are in addition to the examination and any other treatments, and that I am responsible for payment at the time services are rendered. The range of additional costs vary and may exceed $300-$500DNR: I DO NOT authorize the veterinary healthcare team to attempt CPR or other heroic efforts of resuscitation for my pet.
AUTHORIZATION: I hereby authorize the veterinarians at PVRE to examine, treat and prescribe for the above describes pet(s I agree to assume responsibility for all charges incurred in the care of this animal. I understand that all of the charges incurred in the treatment of my pet will be paid in full at the time of discharge. We accept Cash, Visa, MasterCard, American Express, Discover, Debit Card, Care Credit, and Check. WE DO NOT BILL. In the event my pet has an outstanding balance I give my Permission to charge the balance to my credit card or debit card. I also understand that an estimate of these fees for veterinary services will be provided to me, and that I am encouraged to discuss all fees related to such care before services are rendered, and during my pet’s ongoing medical treatment. A prepayment of the estimated fee is required prior to any medical, surgical, or emergency care being provided. Please be advised the state of Arizona’s controlled substance prescription monitoring program requires your date of birth if controlled substances are dispensed to your pet. Prescription drugs may be available at your local pharmacy. PVRE participates with the Maricopa County Attorney’s Bad Check Program: consequently we will ask to make a copy of your Driver’s License. PVRE has doctors and nurses on site 24 hours a day, 365 days a year.

I have read, understand and agree with the above information.
Today's Date: *

MonthDayYear
Date
Signature

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REGISTRATION FORM

Client Information (Pet Owner)

Primary Veterinarian Information

Patient (Pet) Information

Advance Directive: