3410 La Sierra Ave Suite A Riverside, CA 92503 - 951-359-7811 - info@lasierravet.com
Client Authorization Form
Client Information
Have you been here before with other pets?
*
Yes
No
Primary Owner's Name
*
First Name
Last Name
Co- Owner's Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Format: (000) 000-0000.
Co-Owners Phone Number
Format: (000) 000-0000.
E-mail
*
example@example.com
Owner's Birthday (REQUIRED for controlled substances if/when dispensed)
*
-
Month
-
Day
Year
Date
Pet Information
Pet Name
*
Species
*
Canine
Feline
Rodent
Lagomorph
Breed
*
Colors/Markings
*
Pet Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Unknown
Spayed/Neutered
*
Yes
No
Unknown
Does your pet have medical records at a previous clinic that we may contact?
*
Yes
No
If so: Facility Name (or please specify "None Previous"/"Unknown"/etc.)
*
Facility Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Has your pet been vaccinated?
*
Yes
No
If yes, please list vaccinations and dates (or please specify "None Previous/"Unknown"/etc.)
*
Is your pet microchipped?
*
Yes
No
Please Check
Does your pet have any known medical conditions?
*
Yes
No
If yes, please list
Does your pet have any known allergies?
*
Yes
No
If yes, please list
Is your pet currently on any medication, prescription or over-the-counter?
*
Yes
No
If yes, please list
Does your pet have any behavioral issues we should know about?
*
Yes
No
If yes, please list
Pet’s current diet (brand, flavor, amount, etc.):
*
I consent to my pet's photo being shared on La Sierra Veterinary Clinic's website / social media:
*
Yes
No
How did you hear about us?
*
Please Select
Client Referral
Google
Yelp
Social Media
Word-of-Mouth
Veterinary Hospital Referral
Other
If referral, whom?
By signing below, I confirm that I am the owner (or authorized agent of the owner) of above pet and authorize La Sierra Veterinary Clinic to perform services, diagnostics, treatments, and/or administration of extra label medications as deemed necessary by the veterinarian. I understand there is a risk of complication with any procedure and there is no guarantee as to the results of any treatment or procedure. I authorize La Sierra Veterinary Clinic to obtain/release all medical records regarding my pet from/to any other hospital associated with the care of my pet. I understand and agree that portions of my pet's visit may be recorded for educational purposes. I understand that payment is due in full at time of services rendered via cash, check, credit/debit card, Care Credit, and/or Scratchpay, and I am 18 years of age or older.
Date
*
-
Month
-
Day
Year
Date
Authorizing Party Signature
*
Signature Date
Continue
Continue
Should be Empty: