PSCVS - New Client Registration

Owner's Name: *

First Name Last Name

Address *

Street Address

City State / Province

Postal / Zip Code Country

Email *

example@example.com

Phone Number *

Area Code Phone Number

Preferred Method of Contact *

Owner's Date of birth: *

Month Day Year

Partner or other authorized agents name:

First Name Last Name

Additional person's relation to you

Additional person's phone number:

Area Code Phone Number

Do you authorize the above provided Partner/Co-Owner to make urgent decisions if you are unreachable?

Yes No

If your pet currently has pet insurance, please upload a copy of the blank signed form:

Pet's Name: *

Pet's Age/Date of Birth:

Type of Pet *

Canine Feline

What Breed and Color is your Pet? *

Pet's sex:

Male Female Neutered Male Spayed Female

Do you have additional Pets?

Yes No

Pet's Name: *

Pet's Age/Date of Birth:

Type of Pet *

Canine Feline

What Breed and Color is your Pet? *

Pet's sex:

Male Female Neutered Male Spayed Female

Primary Veterinarian's Name

Initial Presenting Problem/ Special Needs/ Concerns:

Consent

I, the undersigned owner or agent of the owner, hereby consent to the examination of my pet by Pacific & Santa Cruz Veterinary Specailists (PSCVS). I agree that after consultation with me, the hospital's Doctors may prescribe medication for, treat, hospitalize, anesthetize and.or perform surgery on my pet. I understand that no guarantee can be made as to the outcome of treatment and that I am encouraged to discuss any concerns I have about the risks of treatment with the attending Veterinarian before any procedures or treatment is initiated.

I understand that a treatment plan including an estimate of the costs 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.

I hereby authorize the name(s) above to make financial and medical decisions for the patient listed. I understand the professional fees are to be paid at the time services are rendered and a deposit is required on all pets admitted to the hospital.

I understand that I (the owner or agent) am financially responsible to PSCVS for all charges relating to this patient. I have read and agree to the treatment authorization. I have also read and accept the financial obligations.

Signature *

Clear

New Client Registration

Patient Information