New Client Form

1
New Client Form* This field is required.
Owner Name
Co-Owner Name
Email
Phone
2
Pet Information* This field is required.
Pet Name
Breed
Sex
3
Referral? How did you get our contact information?
4
In case of an emergency when you cannot be reached, who is authorized to make important decisions or consent to procedures/treatments for your pet?* This field is required.
Emergency Contact Name
How may we contact this person in an emergency?
5
I authorize Lake Seminole Animal Hospital to perform such diagnostic, therapeutic and surgical procedures as are in their opinion, necessary and advisable for treatment and maintenance of my animal’s health and well being. The nature of such procedures has been described to me to my satisfaction. While I expect all procedures to be done to the best of the abilities of the professional staff, I realize that neither guarantee nor warranty can ethically or professionally be made regarding results or cure. I authorize the hospital director and his team to provide veterinary service as requested or in emergency circumstances to follow through with such procedures as necessary for my pet on a continuing basis until further advised.* This field is required.
Initial
6
I understand payment of fees is requested at time of service, release or termination of the case. I understand that I should not hesitate to ask for estimates before services are initiated. I understand interest will be charged at the maximum amount allowed by law on any outstanding balance. If I have a balance for more than 90 days, my account will be forwarded to a collection agency and may be reported to the credit bureau. In that event, I agree to pay a 20% collection fee, plus attorney’s fees and court cost in addition to the balance owed.* This field is required.
Initial
7
CONSENT FOR AUDIO RECORDING DURING VETERINARY APPOINTMENTS
Purpose
Lake Seminole Animal Hospital uses Scribblevet, an AI-powered veterinary scribe, to record and transcribe appointments. The purpose of this recording is to generate accurate medical notes for your pet's health record, allowing the veterinarian working with you to focus fully on your pet during the visit rather than on manual documentation.

How It Works
During your appointment, a device will record the conversation between you and Drs. Rumore, Wrede, O’Connor, Weaver, Mayne or DeRosa.. The audio is securely transmitted to PawfectNotes' servers, where it is transcribed and used to generate a structured medical note (SOAP note). The audio recording is deleted after the note is generated and reviewed by the veterinarian.

Data Privacy & Security
Your privacy is important to us. All recordings are encrypted in transit and at rest. Audio files are automatically deleted after note generation. Transcripts and medical notes are stored securely and are only accessible to authorized staff at Lake Seminole Animal Hospital. Your personal information will never be sold or shared with third parties for marketing purposes. Scribblevet complies with applicable data protection laws in Florida.

Your Rights
Participation is voluntary. You may decline to have your appointment recorded at any time without affecting the quality of care your pet receives. You may request a copy of any medical notes generated from recorded appointments. You may revoke this consent at any time by notifying Lake Seminole Animal Hospital in writing.

Consent
I, the undersigned, acknowledge that I have read and understand this consent form. I voluntarily agree to have my veterinary appointment(s) at Lake Seminole Animal Hospital recorded using Scribblevet AI scribe technology for the purpose of generating medical documentation. I understand that Florida is a two-party consent state, meaning all parties to a conversation must consent before a recording can be made.

State-Specific Note
Florida is a two-party consent state. All parties must consent to the recording. Florida Statute 934.03 requires all-party consent.

Initial *
8
Acknowledgment of Written Prescriptions* This field is required.
I understand my right to receive a written prescription for medication that can be filled at the pharmacy of my choice or by my veterinarian, as provided in s. 474.224, Florida Statutes.
9
Acknowledge Of Video Recorders* This field is required.
I understand that in exam rooms and waiting areas of Lake Seminole Animal Hospital video cameras are present.
10
Authorization for Medical Records Transfer* This field is required.
I authorize Lake Seminole Animal Hospital to transfer medical records, including physical exam findings, bloodwork, procedures, treatments, behavior, as well as notations of recommended and declined services, to specialists, other hospitals, and animal facilities when I have requested such records to be sent, or when is it necessary for medical care for my pets.
11
Acknowledgment of Hurricane Evacuation Zone* This field is required.
I acknowledge that 8578 Park Blvd, Lake Seminole Animal Hospital, is located in a “B” hurricane evacuation flood zone and cannot board or hospitalize pets during a mandatory hurricane evacuation of such zone.
12
Name* This field is required.
First Name
Last Name
13
Date* This field is required.
Date
Year
Month
Day
Should be Empty:

CONSENT FOR AUDIO RECORDING DURING VETERINARY APPOINTMENTS