Pet Service Appointment Form

Hello new friends! Before filling out the form below, please take a moment to read and understand our Company's Terms & Conditions (down below). Once reviewed, click agree to continue. Reminder: CATS & DOGS ARE REQUIRED TO HAVE A UP TO DATE RABIES CERTIFICATE BEFORE BEING ABLE TO SET UP AN APPOINTMENT (unless your veterinarian exempts the rabies vaccine). If you have any questions, do not hesitate to contact via text/call (772) 245-6657. *

CLIENT INFORMATION

Owner's Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

MILEAGE FEE*

I acknowledge that a mileage fee will be applied to each appointment, based on the distance traveled to the service location. This fee will be added to the total cost of the appointment and reflected on the final invoice.

Spouse/Partner/Confidant

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Additional Contact (optional)

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.

PRIMARY VETERINARIAN

Veterinary Clinic/Hospital Name*

Primary Veterinarian Name (if unsure that is okay just type "unsure")

Secondary Veterinarian Name (if unsure / none / N/A that is okay just type "unsure," "none," or "N/A")

Phone Number*

Please enter a valid phone number.

Were you referred by said clinic/hospital?*

YesNo

PET(S) INFORMATION

Do(es) your pet(s) have pet insurance?*

YesNoI prefer not to say

If yes, which insurance company? If none, please type 'none' or 'prefer not to say.' Note: we ask this question because some insurance companies will cover certain services.*

PET'S NAME #1*

File Upload

Please upload Rabies Certificate here for Pet #1 (ONLY REQUIRED for cats and dogs - if your veterinarian has exempted the rabies vaccines, please upload the exempt letter here. NOTE (this is for all cats & dogs only): if you (the owner), does not provide a rabies certifcate or exemption, you will be contacted to attempt to retrieve said rabies cerificate/exemption letter prior to being able to make an appointment. If you are unable to provide such paperwork, as stated in the agreement upon introduction, you will not be able to move forward from here.)

Species*

Breed*

Pet's Age/D.O.B.*

Color(s)*

Gender*

MaleFemaleMale NeuteredFemale Spayed

Temperament*

FriendlyNervous but friendly (not likely to bite)Caution - Fearful/Nervous (likely to bite/nip)Caution - Aggressive (will bite [don't worry, no judgement - we just need to know])

Would this pet require to bring an assistant?*

YesNoUnsure

Does said pet require calming support? (Gabapentin, Trazadone, CBD/Hemp, etc...)

YesNoUnsure

Pet #1: Please share concerning health condition(s), if any. If none, please type 'None at this time.'*

Anything you wish to share about Pet #1? We love their quirks!

PET'S NAME #2

File Upload

Please upload Rabies Certificate here for Pet #2 (ONLY REQUIRED for cats and dogs - if your veterinarian has exempted the rabies vaccines, please upload the exempt letter here)

Species

Breed

Pet's Age/D.O.B.

Color(s)

Gender

MaleFemaleMale NeuteredFemale Spayed

Temperament

FriendlyNervous but friendly (not likely to bite)Caution - Fearful/Nervous (likely to bite/nip)Caution - Aggressive (will bite)

Would this pet require to bring an assistant?

YesNoUnsure

Does said pet require calming support? (Gabapentin, Trazadone, CBD/Hemp, etc...)

YesNoUnsure

Pet # 2: Please share concerning health condition(s), if any. If none, please type 'None at this time.'

Anything else you wish to share about Pet #2? Are they an angel, a troublemaker, or both?

PET'S NAME #3

File Upload

Please upload Rabies Certificate here for Pet #3 (ONLY REQUIRED for cats and dogs - if your veterinarian has exempted the rabies vaccines, please upload the exempt letter here)

Species

Breed

Pet's Age/D.O.B.

Color(s)

Gender

MaleFemaleMale NeuteredFemale Spayed

Temperament

FriendlyNervous but friendly (not likely to bite)Caution - Fearful/Nervous (likely to bite/nip)Caution - Aggressive (will bite)

Would this pet require to bring an assistant?

YesNoUnsure

Does said pet require calming support? (Gabapentin, Trazadone, CBD/Hemp, etc...)

YesNoUnsure

Pet #3: Please share concerning health condition(s), if any. If none, please type 'None at this time.'

Anything else you wish to share about Pet #3? Please share those funny stories!

Service Information

Where did you first learn about us?*

If someone recommended you to us, we would love to know who!

Preferred approximate appointment time

* - Evenings are considered outside normal operating hours. Services requested after 6:00 PM (no later than 8pm) will be subject to a $50 after-hours fee. This allows us to provide high-quality care while maintaining sustainable business operations. In case of a true emergency, please contact for immediate assistance:

Veterinary Medical Center of St. Lucie County

7790 S U.S. Highway 1, Port St. Lucie, FL 34952

P#: (772) 337-8570

OR

Pet Emergency of Martin County

2239 S Kanner Hwy, Stuart, FL 34994

P#: (772) 781-3302

Choose Preferred Form of Payment Option (we do not accept checks from first time clients)*

Invoice *recommendedZelleCash

If you chose invoice, okay to send via:

Text &/or EmailEmail only

I authorize Vet Tech 2 U, LLC to take photographs, motion picture, videotapes, or other visual media of my pet(s) which may be used for: patient records, educational purposes which may include: sending the media to you to show for your education, showing the media to other associates of Vet Tech 2 U, LLC, publishing for social media purposes (Facebook, Instagram, Website, promotional material, etc.) and I also understand that there is no royalty, fee, or other compensation for such use. I agree to make no claim to them now or in the future, and release Vet Tech 2 U, LLC from any liability in connection with the approved use of these materials. I understand that is optional and if I elect to not agree, NO media of my pet will be taken by Vet Tech 2 U, LLC.*

Yes, I AGREE to the Photography, Videography and Social Media Waiver.No, I DO NOT agree to the Photography, Videography and Social Media Waiver.

Medical Documentation & Veterinarian Communication Consent (if deemed a medically necessary housecall): I understand that even if I decline consent for social media or photography use, there may be circumstances where medical documentation must be shared with my primary or assigned veterinarian for the purpose of providing safe, accurate, and continuous care. I acknowledge and agree that Vet Tech 2 U, LLC will only share relevant medical information when it is medically necessary and strictly for veterinary care purposes. This may include retrieving or sending treatment notes, observations, test results, or other documentation required to support my pet’s health and well-being. I understand that if I do not consent to medically necessary communication with my veterinarian, Vet Tech 2 U, LLC may be unable to provide services, as coordination with my veterinarian is essential to delivering appropriate and exceptional care.

I authorize Vet Tech 2 U, LLC to share medically necessary information with my pet’s primary or assigned veterinarian for the sole purpose of coordinating and supporting my pet’s medical care. I understand that this communication may include treatment notes, observations, diagnostic information, and other relevant medical documentation. I acknowledge that this information will only be shared when medically appropriate and strictly for veterinary care purposes.I understand that by declining authorization for Vet Tech 2 U, LLC to communicate medically necessary information with my pet’s veterinarian, services may be limited or declined. I acknowledge that coordination with my veterinarian may be essential to providing safe, appropriate, and exceptional care.By selecting this option, I understand that Vet Tech 2 U, LLC reserves the right to refuse or discontinue services if proper medical communication is not permitted.

Signature*

New Client & Pet Service Form

CLIENT INFORMATION

PRIMARY VETERINARIAN

PET(S) INFORMATION

Please give the site a moment to upload your information; it will let you know when it's done. Please do not click back.