History and Registration Form - NEW CONSULT / Evansville

Please CONFIRM that you are wanting to visit our
Internal Medicine service in EVANSVILLE, INDIANA.

If you selected the wrong location, please reschedule your appointment. For assistance or questions, call 502-901-7990.
What to Expect at Your Pet’s Appointment

Please allow at least one hour for your pet’s initial consultation. Depending on the evaluation, diagnostic testing, and treatment you authorize, your pet may need to stay with us for several hours or most of the day. Our team will keep you informed about the anticipated timeline.

By scheduling this appointment, you are committing only to the consultation fee. The consultation includes:
- A thorough review of your pet’s previous medical records
- A complete physical examination
- A discussion with our medical team about your pet’s condition and recommended next steps
If diagnostic testing or treatment is recommended, we will explain your options and provide a detailed estimate before proceeding. No additional services will be performed without your approval.

You will speak with one of our board-certified veterinary specialists about your pet’s evaluation, diagnostic recommendations, and treatment plan. Our doctors work collaboratively, so multiple doctors and medical team members may contribute to your pet’s care.

Within 24 hours of the appointment, you will receive emailed medical records from VSP summarizing your pet’s visit, our recommendations, and the results of any testing performed.

We understand that specialty appointments can feel overwhelming. Please ask questions at any time—we want you to feel informed, supported, and comfortable with your pet’s care.

When you arrive, please text (502) 901-7990 with your vehicle’s: color, make, and model. A team member will meet you outside and escort you and your pet to an exam room.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Client and Patient Registration
Client's Full Name

First NameLast Name
Client's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearWhy do we need your date of birth? The state of IN now requires us to query its database prior to prescribing controlled substances and many medications that we would use to help control pain in your pet. This database requires your date of birth.
Co-Owner / Partner

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Email
example@example.com
Matching Email
example@example.com
Patient's Name
Species
Signalment
Breed
Patient's Date of Birth. (estimate if unknown)

MonthDayYear
2 digit month, 2 digit day, 4 digit year(mm-dd-yyyy)
Referring Veterinarian
Referring Veterinarian Hospital Name
Authorization to Treat

You have requested an Internal Medicine consultation with Veterinary Specialist Partners (VSP) for your pet. The initial consultation may include imaging and additional procedures depending on recommendations and your consent. Veterinary Specialist Partners will provide in-person consultation, physical exam, and various other diagnostics on the day of the appointment. Follow-up testing recommendations will be discussed and performed as indicated. In the case that sedation/anesthesia is required, you understand that while the complication rate is low there are inherent potential risks, up to and including death, with any sedated procedure. Sedation will not be given without prior consent from you.

You will receive written discharges within 24 hours of the appointment (either hard copy or via email), and your primary care veterinarian will receive a copy as well. This document will detail the physical exam findings, any imaging results, and other pertinent information from the consultation as well as recommendations for follow-up diagnostics and treatment.

The initial consultation includes patient exam, review of historical diagnostics and medical records, and discussion about further diagnostic and treatment recommendations. All other costs will be determined based on testing recommended and will be presented in an itemized estimate for approval. Your signature below authorizes VSP to perform their initial consultation. Payment is due at the time of service and can be made via cash, personal check, VISA, Mastercard, Discover, American Express, Cherry, CareCredit, or Scratch Pay. Please note that a 3% processing fee applies to credit card transactions. To avoid this fee, we also accept cash and debit cards.
Client Signature

Authorization for Medical Records Release, Use of Image/Likeness of Pet, and AI Technologies

Evidenced by your signature, you authorize the full release of any and all medical and veterinary records, correspondence, pictures, videos, and any likeness of your Pet to be utilized by Veterinary Specialist Partners and/or shared with other veterinarians (including your primary veterinarian), scientists, or similar professionals. These materials may be used for diagnosis, treatment, or other care of your Pet; educational purposes, including online forums and presentations; statistical and scientific research; and advertising for Veterinary Specialist Partners.

Additionally, you consent to the use of advanced AI technologies in the processing, analysis, and utilization of this information. AI may be employed for analyzing medical records to support diagnosis or treatment, creating educational content, and enhancing the accuracy of statistical and scientific research.

You understand that medical information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

You, the undersigned, release and discharge Veterinary Specialist Partners, LLC, and its employees and agents (the “Covered Entities”) from all liability related to the use and/or disclosure of this information. You agree to hold the Covered Entities harmless for any use and/or disclosure made in accordance with this authorization.

This authorization will remain in effect from the date of signing until revoked in writing, with written notice delivered to the Covered Entities.

A photocopy of this authorization shall be as effective as the original. By signing below, you acknowledge and agree to the use of the described technologies and authorize the release of the records and likenesses for the specified purposes.
Client Signature

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Client and Patient Registration

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