Welcome to Arroyo Vista Veterinary Hospital!
Thank you for giving us the opportunity to care for your pet. To insure the best care possible, please fill out this form in its entirety. Thank you!!
Pet Owner Information
Primary Owners Name
*
First Name
Last Name
Primary Phone Number
*
Secondary Owners Name (if applicable)
First Name
Last Name
Secondary Phone Number (if applicable)
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Drivers License # (required for check payments)
example@example.com
Drivers License # (required for check payments)
Previous Veterinarian
How did you hear about us?
*
Please Select
Google
Yelp
Social Media
Self
Referral (Please specify...)
Other (Please specify...)
Other
*
I was referred by
*
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Pet Details
Pet Name
*
Please upload a photo of your pet
Browse Files
Drag and drop files here
Choose a file
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of
Species
*
Please Select
Canine
Feline
Rabbit
Rodent
Other (please specify)
Other
*
Birthdate (please approximate if unsure)
*
/
Month
/
Day
Year
Date
Breed
*
Color
*
Sex
*
Please Select
Female
Male
Is your pet Spayed/Neutered?
*
Yes
No
Unsure
Does your pet have a microchip
Please Select
Yes
No
Unsure
Microchip number
May we use photos/stories of your pet online? Personal information will not be shared.
*
Yes
No
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Acknowledgements
Please review and mark that you have read and understand each statement below.
I understand that payment is due, in full, at the time of service. Some procedures require a deposit. Cash, checks, Visa, MasterCard, Discover, American Express and Care Credit are accepted.
*
I understand
I understand that the Arroyo Vista Veterinary Hospital processes checks electronically. By providing my drivers license number, I authorize the electronic processing of my checks. All returned checks are subject to a return fee of up to $30.
*
I understand
I understand that the Arroyo Vista Veterinary Hospital requires that all pets have a current health examination with one of their doctors for any treatment including, but not limited to, vaccinations, prescriptions refills, lab tests and dental cleanings.
*
I understand
I understand that all prescriptions must be authorized by a doctor and that they may take up to 24 hours for refills to be processed. Reception staff cannot authorize refills.
*
I understand
I understand that copies of medical records may require 48 hours notice.
*
I understand
By signing the below line, you state: I am the owner or authorized agent of the pet presented for care. I authorize the Arroyo Vista Veterinary Hospital to examine, prescribe for and treat the above stated pet. I have read this form in full and completed it to the best of my knowledge.
Signature
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