Client/Patient Information

Patient Information
Pet's Name*
Species*

CanineFelineOther
Breed *
Color*
Gender*

MaleFemaleNeutered MaleSpayed Female
Date of Birth/Age of Your Pet*
Primary Care Veterinarian: *
Hospital Name*
Please write none if you do not have one.
Other Veterinarian:
Hospital Name:
Has your pet been seen at an ER/Urgent Care facility recently?*

YesNo
If yes, please list when:
ER/Urgent Care Facility Name:
Preferred Pharmacy: *
Preferred Pharmacy Phone:
Acknowledgement of Financial Responsibility

I understand that payment is due at the time that services are rendered. I also understand that I am responsible to pay services rendered, including reasonable attorney’s fees and costs of collections in the event of default.

Client Code of Conduct Agreement

I have the right to: considerate, respectful, and compassionate care, information about my pet's diagnosis, prognosis, as well as options for testing and treatment; and financial estimates for the cost of care. I understand that any abusive, disrespectful, and/or inappropriate behavior could result in my dismissal from Summit Veterinary Referral Center and discontinuation of my pet's care.
Signature*

Clear
Date

MonthDayYear
Date