Client Name
*
Prefix
First Name
Last Name
Best Contact Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Spouse/Significant Other
First Name
Last Name
Spouse/Significant Other Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you authorize text communication
*
Yes
No
Patient(s)Information
*
Pet's Name
Species
(Cat/Dog)
Breed
Sex
Spayed/Neutered
(Yes/No)
Date of Birth
Color
1
2
3
4
5.
6.
Client Consent
Please review the below and acknowledge your consent with company policies
Informed consent
Please Select
I Certify
I certify that I am over 18 years of age and assume full responsibility for all costs associated for services and/or treatments performed on my pets. Should my account become delinquent, I will be responsible for all collection costs, including, but not limited to the balance, attorney fees, court costs, collection agency fees and interest at the rate of 1.5% per month.
Late or Missed Appointment Policy
*
Please Select
I Consent
I understand that a fee of $60.00 will be charged for any one pet's “No-Show” or canceled appointment without 24 hours' advance notice, and a fee of $100.00 will be charged for any double pet “No-Show” or canceled appointment without 48 hours' advance notice. I understand that if I arrive 15 minutes late to my appointment, I may incur a $25 fee, and my appointment may need to be rescheduled. If I have two “No-Show” or canceled appointments within a year, I will be required to place a deposit of $60.00 before being scheduled for any future appointments and $150.00 for any surgeries or dental procedures.
Medication Consent
*
Please Select
I Consent
I Do Not Consent
I acknowledge that many of the medications prescribed by veterinarians may not be FDA-approved for all animal species or uses and may be considered “off-label.” However, I understand this is a legal and well-accepted practice in veterinary medicine. If deemed necessary, I consent to the use of medications administered “off-label” for treatment.
Medication Refill
*
Please Select
I Consent
Downtown Pet Hospital requires a 48 hour notice for all medication refills. For critical daily medications and/or controlled medications, a 72 hour notice is requested
Photography and Medical Information Release
*
Please Select
I Consent
I Do Not Consent
I understand that Downtown Pet Hospital may take photographs or videos of my pet and use their medical information for teaching, veterinary literature, marketing, and publishing. I authorize the release of my pet's photographs for such purposes, with client privacy and medical confidentiality being maintained.
Audio Recordings
Please Select
I consent
I do not consent
I understand that Downtown Pet Hospital Doctors may use audio recordings during my pet's examination. These recordings are solely used to record the pet's medical history and are transferred into the pet's medical records. Client privacy and medical confidentially will be maintained.
CPR/DNR
*
Please Select
I authorize Cardio Pulmonary Resuscitation (CPR)
I elect to Do Not Resuscitate (DNR)
In the event of an emergency, we would like to plan in advance what your wishes are if your pet(s) stop breathing and/or their heart stops beating.
Code of Conduct
*
Please Select
I Consent
I understand that all pet owners are required to communicate with team members and other pet owners in a kind and respectful manner. Aggressive, threatening, harassing, or bullying behavior will result in dismissal from the practice.
Pet Behavior and Care
*
Please Select
I Consent
I understand that all dogs must be on a leash, and all cats must be in a carrier or on a leash while at the hospital. Pet owners are responsible for their pets' behavior. I will inform team members if my pet has a history of aggression or severe anxiety.
Service Refusal
*
Please Select
I Consent
I understand that Downtown Pet Hospital reserves the right to refuse service to anyone.
Deposits and Payments
*
Please Select
I Consent
For all medical care, services, and treatments performed at Downtown Pet Hospital, payment is due at the time services are rendered. If my pet is hospitalized, I will be required to pay 50% of the treatment plan as a deposit before admission, with the balance due upon discharge. I may also be asked for additional payments if further treatments are necessary during hospitalization. A $150.00 reservation fee will be required to schedule any surgical or dental procedures performed by our veterinarians. We accept Cash, Visa, MasterCard, Discover, American Express, and third-party funding options, such as Care Credit.
Understanding/Acknowledgment/Agreement
My signature below indicates and acknowledges that I have read and fully understand and consent to the policies and procedures as listed above by Downtown Pet Hospital.
Signature
*
Submit
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