New Patient Registration Form of Antigua Veterinary Practice

Client Information
Client Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email Address
Other Name on Account That Can Authorize Treatment
Patient Information
Prescription Rights Acknowledgement (Fl Statute 474.224)
During the 2026 legislative session, the State of Florida enacted section 474.224, Florida Statutes, effective July 1, 2026.

"I understand the veterinary client's right to receive a written prescription for the medication that can be filled by the pharmacy of my choice or my veterinarian, as provided in s. 474.224, Florida Statutes."
Signature Of Acknowledgement
Client Name (Printed)
Date

MonthDayYear
Signature
Office Use Only
Client Account #
Acknowledgement Recorded
Staff Initials
Date

MonthDayYear
Should be Empty: