New Client Form

Thank you for entrusting your pet to our care!

Please complete the following information for yourself and your pet.

Name*

First NameLast Name

Co-Owner's Name

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner's Date of Birth*

Date

Primary Phone Number*

Area CodePhone Number

Co-Owner's Phone Number

Area CodePhone Number

Email Address*

Name*

Age OR Date of Birth*

Species*

Breed*

Color*

Sex*

Intact FemaleSpayed FemaleIntact MaleNeutered Male

South Temecula Veterinary Hospital has my permission and the right to take photographs of my pet, and to copyright, use, and publish the same in print and/or digital media.*

Yes, I agreeNo, I do not agree

Do you have copies of your pet's medical records with you today?*

YesNo

If no, who do we contact for your pet's records?

Phone Number

Area CodePhone Number

I understand that every effort will be made to achieve a successful outcome and to ensure the safety of my pet during hospital care and handling. However, I acknowledge that the outcome of my pet’s medical treatment is not guaranteed.

I hereby authorize the hospital to receive, prescribe for, treat, or perform surgery on the pet listed above. Furthermore, I agree to pay all fees for services rendered at the time my pet is discharged from the hospital or when the service is otherwise terminated.

In the event that collection efforts are necessary, I agree to pay the reasonable costs of collection, attorney fees, and court costs. I understand that products and medical treatments are non-refundable.

I agree that any legal action will take place in the county where the hospital is located. Additionally, I understand that veterinary care is not provided overnight.

Finally, I agree to release South Temecula Veterinary Hospital, National Veterinary Associates (NVA), and all of their employees or independent contractors from any liability related to my pet's medical treatment.

I am at least 18 years of age and legally liable for the decisions I make.

Date*

Date

Client Information

Patient Information

Social Media Consent

Medical Records