History and Registration Form - NEW CONSULT / Louisville

Please CONFIRM that you are wanting to visit our

Internal Medicine service in LOUISVILLE, KENTUCKY.

**If this is the wrong location, please reschedule your appointment. Call 502-901-7990 with any questions.
- These appointments typically take 1 hour minimum, and can take most of the day depending on the work-up that is approved.
- Estimates will be provided for ALL testing and treatments and discussed with you before anything is done. The only fee you are committing to by scheduling the appointment is the $175 consultation fee, which includes complete review of all previous medical records, physical exam, and talking with our internal medicine specialty team about your pet's suspected diseases.
- You will talk with one of our doctors, Dr. Scott Rizzo or Dr. Grace Clark, and discuss diagnostics and treatment recommendations, although this is a shared service so both Drs. Clark and Rizzo will take part in the care of your pet.
- You will also receive written medical records from VSP within 24 hours of the appointment detailing what was recommended and results of any testing performed.
- When you arrive for your appointment, pleast text (502) 901-7990 with a description of your vehicle (color, make, model) so we know you have arrived, and we will come out to get you and place you into an exam room with your pet.
Date*

MonthDayYear
Client and Patient Registration
Client's Full Name*

First NameLast Name
Co-Owner / Partner

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Secondary Phone Number (optional)
Email*
example@example.com
Matching Email
example@example.com
Patient's Name*
Species*
Signalment*

FemaleFemale spayedMaleMale neutered
Breed*
Patient's Date of Birth. (estimate if unknown)*

MonthDayYear
(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 is $175 which 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 required at the time of the services rendered via cash, personal check, VISA, Mastercard, Discover, American Express, CareCredit, or Scratch Pay
Client Signature*

Clear

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*

Clear

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Client and Patient Registration

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