New Client Form - Redwood Veterinary Hospital

New Client Information

All fields marked with * are required and must be filled.
Before we start, please tell us how you heard of Redwood Veterinary Hospital (friends/family, yellow pages, drive by, etc.)
Can we thank anyone in particular for recommending us?
Name*

First NameMiddle InitialLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Employer*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a spouse/partner you would like to add?

YesNo
Name

First NameMiddle InitialLast Name
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
PROFESSIONAL FEES ARE TO BE PAID AT TIME OF SERVICES.

FOR YOUR CONVENIENCE WE ACCEPT CASH, CHECK, DEBIT, VISA, MC, DISCOVER, AMER X, SCRATCHPAY AND CARE CREDIT
Pet Owner Signature*
Today's Date*

MonthDayYear
Date

Redwood Veterinary Hospital Terms and Conditions
As a condition of treatment by Redwood Veterinary Hospital. I/We, being the Responsible Party, 18 years of age or older, understand that payment is due at the time that medical services are rendered. My signature below forms a binding agreement between Redwood Veterinary Hospital and the Responsible Party who is requesting and receiving Veterinary Services for a patient. I/We understand that all financial arrangements must be made prior to any services being rendered. The Responsible Party is the individual who is financially responsible for payment of all Veterinary Services. All charges for Veterinary Services rendered are due and payable at the time the service is rendered. The Responsible Party agrees to pay interest at the rate of 0.83% per month (10% per year) on any past due balances.

Express Consent to contact via cell phone:
I give my express permission to contact me at all my phone numbers including, but not limited to, my current cell phone or any cell phone number that I may have in the future, for the purposes of communication regarding my account including, but not limited to, obtaining information to keep my account current and to collect a debt that I may owe. This permission shall also transfer to any agent on behalf of creditor including a third party to enforce the collection of any debt I owe to creditor.

Pet Medical Insurance:
The Responsible Party is responsible for all charges for Veterinary Service to be paid at the time of service. Redwood Veterinary Hospital will provide the Responsible Party with any paperwork necessary for reimbursement of their claim.

Returned Check Policy:
If a payment is made on an account by check, and the check is returned by your bank for any reason, the Responsible Party will be responsible for the original check amount in addition to a $20.00 Service Charge and all associated restitution fees.

Non-Payment of Account:
Payment is due at the time that services are rendered. It is our policy to refer all unpaid accounts to our collection agency. Should collection referral or legal action become necessary to collect an overdue account, the Responsible Party, understands that we have the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for Veterinary Services rendered. Responsible party further agrees that in the event legal action is undertaken to collect monies due, the prevailing party will be entitled to costs of suit and reasonable attorney’s fees. In the event legal action is undertaken, Solano County California shall be the proper county in which they commence legal action.
- I/We understand my financial obligations related to the Veterinary Services rendered as specified above.
- I /We agree to inform you of any changes in my residence or work information
- I/We agree to allow and authorize contact at any phone numbers unless permission is expressly rescinded now or in the future for the purposes of communication regarding my account including, but not limited to obtaining information to keep my account current and to collect a debt that I may owe. This permission shall also transfer to any agent on behalf of creditor including a third party to enforce the collection of any debt I owe to creditor.
  By signing below, you verify that you are 18 years of age or older, you agree to accept full financial responsibility for any pet(s) that is/are receiving Veterinary Services. Your signature verifies that you have read the above information, understand your responsibilities, and agree to the terms.
By signing below, you verify that you are 18 years of age or older, you agree to accept full financial responsibility for any pet(s) that is/are receiving Veterinary Services. Your signature verifies that you have read the above information, understand your responsibilities, and agree to the terms.
Name*

First NameLast Name
Client Signature*
Today's Date*

MonthDayYear
Date

Notice of Change in Privacy Policy
The Solano County Animal Control Services Division has informed Redwood Veterinary Hospital that Solano County has privatized the dog licensing program by contracting with PetData, Inc, an out-of-state company based in Irving, TX. PetData Inc. specializes in the business of animal licensing and services many areas around the United States. Solano County Ordinance Article IX, Sec. 4-152, which states:

Every licensed veterinarian in the county shall submit, at a frequency to be determined by the animal control director, but not more frequently than every two weeks, a record of the names and addresses of the owners of those dogs which he or she has administered rabies vaccination, and a brief description of the animal vaccinated during the immediately preceding reporting period. (Ord. No. 1207, § 1, Rev. 12/97)

Solano County is requiring this reporting of rabies vaccinations and owner information by local veterinarians to improve licensing within the county.

Redwood Veterinary Hospital, Inc has always respected the privacy of our clients and has always declined to release client information to a third party without specific client permission or by order of a court of law. We have learned through the Napa-Solano Veterinary Medical Association and through the California Veterinary Medical Association that there is legal precedence that allows Solano County to require veterinarians to release previously confidential client information to them, even through a third party such as PetData, Inc. We have been assured, both by Solano County and by PetData, Inc that the client information we release, as required by county ordinance, "will be kept strictly confidential and will be used for the sole purpose of ensuring compliance with Solano County ordinance codes, and the information will only be available to PetData, Inc and Solano County Animal Care Offices."1

By signing below, you are acknowledging that you have been informed of this privacy policy.
Name*

First NameLast Name
Client Signature*
Today's Date*

MonthDayYear
Date

Notice to All Cat Owners
The doctors at Redwood Veterinary Hospital have always believed that an informed pet owner is a good pet owner. In that spirit we would like to share with our cat owning clients some concerns about Feline Leukemia virus and Rabies virus vaccines. Recent University and Industry sponsored studies have shown a clear relationship between the use of Feline Leukemia and Rabies virus vaccines and the development of cancerous tumors (Fibrosarcoma) at the site the vaccine was administered. The prevalence of this problem is very low (annual prevalence estimates range from 3-4 cases per 10,000 cats). Nevertheless, we feel it is important for all cat owners to be aware of the slight risk. In light of these findings we make the following recommendations:
1. For cats that go outside of the house (full or part time) or cats that are exposed 1. to such cats, we recommend routine Leukemia and Rabies virus vaccination programs.
2. For "indoor only" cats, we recommend that the owner discuss each individual case with their pet's doctor.
3. When possible, Redwood Veterinary Hospital will administer all Rabies and Leukemia virus vaccines in the lower leg regions, where therapy is much more effective in the unlikely event that a tumor should develop.
4. Cat owners should periodically monitor the sites where the vaccines are given and notify us of any concerns.
Please sign and date below verifying that you have been informed of this issue.
Name*

First NameLast Name
Client Signature*
Today's Date*

MonthDayYear
Date

Authorization for Release of Pet Health Information
Client Name*

First NameLast Name
The person(s) named above authorize information of all pets vaccine and medical information to be requested or released by representatives of Redwood Veterinary Hospital .
- Referral / transfer to UC Davis or any Specialty/Emergency Facility-All information/communication/images regarding assessment, diagnosis, and treatment of pets's condition, concern, or disease.
- Other Veterinary Hospitals-Copy of complete medical/immunization record.
- Pet Medical Insurance- All information/communication regarding assessment, diagnosis, and treatment of pets's condition, concern, or disease.
- Boarding Facilities- All information regarding immunizations.
- Grooming Facilities-All information regarding immunizations.
Please note: Unless otherwise specified by law, we will release only the information which has been created by Redwood Veterinary Hospital , including chart notes, lab results, summaries, and consultation reports. Records created by and available from other providers, hospitals, or other care facilities must be obtained directly from those other providers or facilities.

The information you are authorizing to be released could be re-released or disclosed by the recipient. Such additional disclosures or releases may not be prohibited by law. We are not responsible for the actions of others who may be provided with information released as a result of this authorization.

**We will happily transfer copies of your pet(s) records directly to the above facilities via email at no charge to you. However, a fee will be charged for additional copies requested for personal use.

I authorize Redwood Veterinary Hospital to release medical information for all pets under my account to any of the above listed facilities.
Client Signature*
Today's Date*

MonthDayYear
Date

Controlled Drug Information Release
Redwood Veterinary Hospital has always kept careful records of the prescriptions we fill for our animal patients. One group of drugs called “Controlled” drugs requires special record keeping. Controlled drugs include medications such as Phenobarbital, Butorphanol, Diazepam, Hycodan/Tussigon, Tramadol, and Buprenorphine. To dispense these Controlled drugs we have long been required to file special reports to the United States Drug Enforcement Agency (DEA) and the California Department of Justice. These drugs are important medical tools in managing a wide range of problems from seizures to pain, and we have always believed the benefits they hold for our patients far outweigh the inconvenience of the added work in keeping and filing these records. To legally dispense these drugs we must abide by all Federal and State laws regarding their use and dispensation.

Effective January 1, 2007, The California Department of Justice requires all veterinarians who dispense Controlled drugs submit (on a weekly basis) the names, birth dates, and addresses of all clients purchasing Controlled drugs for their pets. This includes new prescriptions as well as refill prescriptions. Commercial pharmacists will also need to file these reports. For us to dispense this type of medication for your pet, we will need your authorization (by signing below) to release this information to the California Department of Justice. Please remember this information will only be filed with the State Department of Justice if a Controlled drug is dispensed for your pet. Otherwise, as usual, your personal information will be kept strictly confidential.

I understand the above requirements for my pet(s) to receive a Controlled drug prescription from

Redwood Veterinary Hospital and authorize the release of my name, address and birth date to the California Department of Justice.
Client Signature*
Today's Date*

MonthDayYear
Date
Client Full Name*

First NameMiddle INitialLast Name
Date of Birth*

MonthDayYear
Date
Should be Empty:

New Client Information

Redwood Veterinary Hospital Terms and Conditions

Notice of Change in Privacy Policy

Notice to All Cat Owners

Authorization for Release of Pet Health Information

Controlled Drug Information Release