South Bay Veterinary Hospital

South Bay Veterinary Hospital

Welcome to our Family!
Name *

First Name Last Name,
Co Owner - Last Name
Co Owner - First Name
Street *
Apt #
City *
State *
Zip *
Please fill out the information below and circle the best way for us to reach you.
Home Phone

Area Code Phone Number
Owner - Cell Phone

Area Code Phone Number
Owner - Work Phone

Area Code Phone Number
Co Owner - Cell Phone

Area Code Phone Number
Co Owner - Work Phone

Area Code Phone Number
E Mail Address *
example@example.com
Owner's DOB (necessary for payment and prescriptions) *
How did you hear about us? *

Sign/Drove by YELP Veterinarians.com Facebook Online/Internet/Web Other Referred by a friend (please comment below to tell us who we may thank): Other (please comment below to tell us where you heard about us):
Photo Release - I do hereby consent and agree that South Bay Veterinary Hospital, its employees, or agents have the right to take photographs or digital recordings of my pet(s) and release all rights to exhibit this work in print and electronic form publicly or privately. I also understand that South Bay Veterinary Hospital is not responsible for any expense or liability incurred as a result of the aforementioned participation in any photographs or recordings. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement *

Yes, I give permission for my pet's photo to be used as noted above. No, please do not use my pet's photo.
We strive to make you a part of your pet's health care and understand you would like to be present for treatments. However, certain treatments need to be done in our treatment area. For your and your pet's safety

I understand that I am financially responsible for all charges. If it becomes necessary to hire an outside agency to collect payment for my account, I agree to pay any and all collection charges, billing fees, and legal fees. Note that an $8.00 per month billing fee will be applied to all balances on account over 30 days. Party responsible for authorizing and paying for services, please sign below.
Signature *

Clear
Date *

Month Day Year
Date
Professional fees are to be paid at the time that services are rendered.

We accept Cash, Checks, Debit Card, PayPal, Master Card, Visa, Discover, American Express and Care Credit
PET INFORMATION
Appointment Date *

Month Day Year
Date
Pet's Name *
Species *
Breed *
Date of Birth / Age *
Color *
Sex *
Vaccine History - Please indicate the date your pet last received the following recommended vaccines.
FVRCP *
Leukemia *
Rabies *
DAPP *
Lepto *
Bordetella *
Rabies *
Cats Has your cat had a Leukemia or FIV blood test, if so what date?

Month Day Year
Date
Dogs Has your dog had a heartworm blood test, if so what date?

Month Day Year
Date
Has your pet had a fecal test, if so what date?

Month Day Year
Date
How many hours a day does your pet spend outdoors?
What type of flea and heart worm preventative are you currently using?
Any prior history of illness or surgery?
Is your pet currently on any medications? (Please indicate the dosage and duration)
Does your pet have any drug allergies?
Any concerns regarding your pet’s behavior? (i.e. housebreaking/litterbox training, digging, barking, inappropriate chewing)
What does your pet eat? (Please indicate how much and how often)
Does your pet receive any treats or extras? (Please explain)
Thank you for allowing our hospital the opportunity to care for your pet!
CONTROLLED SUBSTANCES AUTHORIZATION
Dr. Jagpal Deo, DVM and Associates

The following agreement relates to your pet's use of a controlled substance prescribed by a licensed veterinarian at SOUTH BAY VETERINARY HOSPITAL.

CURES is a database of Schedule II-VI controlled substances prescribed in the state of California. It was established by the Drug Enforcement Agency and Department of Justice in 2006 to reduce prescription drug abuse and diversion without affecting legitimate medical practice or patient care. California Law (Health and Safety Code 11165.1) requires us to report all controlled substances dispensed and provide specified dispensing information to the Department of Justice on weekly basis. If the licensed veterinarian recommends a controlled substance for your pet's condition, these regulations must be met:

1. Owner's date of birth must be provided (MUST BE 18 YEARS OR OLDER)

2. By law, a maximum of thirty days supply of medication will be prescribed at any one time.
Pet Name *
Date *

Month Day Year
Date
Signed *

Clear
Owner's Printed Name *
Date of Birth (Owner / Client) *

Month Day Year
Date
I decline to give this information and understand that my pet will not be dispensed any controlled substances.
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South Bay Veterinary Hospital

PET INFORMATION

CONTROLLED SUBSTANCES AUTHORIZATION