Client and Patient Registration Form
Owner Information
Owner's Information (Responsible Party, Primary Contact)
*
First Name
Last Name
Parking Spot Number
*
Primary Phone (cell preferred)
*
Please enter a valid phone number. We may send SMS messages to this number
Format: (000) 000-0000.
Type of phone
*
Please Select
Cell
Land line
Alternate backup phone
Please enter a valid phone number
Format: (000) 000-0000.
Type of phone
Please Select
Cell
Land line
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's birthdate (Please be advised, the state of California’s controlled substance prescription monitoring program requires your date of birth)
*
Month/date/year (For example, birthday of January 1 2020 is entered as 01/01/2020)
Secondary Contact Person
First Name
Last Name
Secondary contact phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to primary contact
Spouse
Relative
Friend
Other
Family Veterinarian Information
Family Veterinarian Hospital/Clinic Name
*
If none, please write N/A
Family Veterinarian Name
If none, please write N/A
Pet Information
Pet's Name
*
Pet's date of birth or age
*
Type in either date of birth or estimated age
Age is listed in
Date of birth
Years
Months
Species of pet
*
Please Select
Canine (dog)
Feline (cat)
Other
If other selected, please indicate species here
Sex and neuter status (select one)
*
Female, spayed
Female, not spayed
Male, neutered
Male, not neutered
Breed
*
Example: Labrador Retriever, Retriever mix; for cat indicate short hair or long hair
Color of Pet
*
Is it okay to use photos of your pet on our social media? *No personal information will be released*
Please Select
Yes
No
In the unlikely event your pet requires CPR, select your advanced directive
*
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 $500. These costs are due at the time services are provided.
DNR: I DO NOT authorize the veterinary healthcare team to attempt CPR or other heroic efforts of resuscitation for my pet.
In the unlikely event your pet requires CPR, select your advanced directive
*
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 $500. These costs are due at the time services are provided.
DNR: 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 MedVet to examine, treat and prescribe for the above describes pet. 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. A prepayment of the estimated fee is required prior to any medical, surgical, or emergency care being provided. Prescription drugs may be available at your local pharmacy. MedVet Silicon Valley has doctors and technicians on site 24 hours a day, 365 days a year. I have read, understand and agree with the above information.
*
I have read and understand the above information
Signature
*
Submit
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