New Client Form - Emergency Care Violet Crown Veterinary Specialists

WELCOME. Thank you for giving us the opportunity to care for your pet. We will be happy to answer any questions you have about your pet's health. Please take the time to fill in this form completely so we may better serve you.
PERSON RESPONSIBLE FOR MEDICAL AND FINANCIAL DECISIONS REGARDING PATIENTS
First and Last Name*
Signature*

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OWNER INFORMATION
Name*

Owner First NameOwner Last Name
Drivers License Number*
Photo of Drivers License*

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Primary Email Address*
example@example.com
Street, City, State, Zip Code*
Owner Phone Number*
Can we text the owner at this number?*
Owner Additional Phone Number
Co-Owner Name

CoOwner First NameCoOwner Last Name
Co-Owner Cell Phone Number
Co-Owner Email Address
example@example.com
Please select "Yes" if you have an active duty military or first responder ID card on you at this time. If not, leave blank.

Yes
Do you or anyone who will be accompanying your pet to our facility have a disability that we should be aware of in order to provide assistance or accommodations?

YesNoPrefer not to say
If yes, what type of accommodation can we provide to make your visit more comfortable? (Select all that apply?)

Wheelchair-accessible entrance/exam roomAssistance with opening doorsHelp carrying your pet or pet suppliesA quiet waiting area (for sensory sensitivity or anxiety)Communication assistance (e.g., writing, visual aids, etc.)Service animal-friendly accommodationsOther
Will you be accompanied by a service animal during your visit?

YesNo
Do you need assistance filling out forms or understanding written materials?

YesNo
Preferred communication method:

Written instructionsEmailText messageSign language interpreterOther
PATIENT INFORMATION
Reason for Referral or Visit*
Patient Name*
Breed*
Colors*
Species*

CanineFelineOther
Sex*

MaleFemaleMale NeuteredFemale Spayed
Date Of Birth*
Patient Name #2
Breed
Colors
Species

CanineFelineOther
Sex

MaleFemaleMale NeuteredFemale Spayed
Date Of Birth
REFERRAL INFORMATION
Primary Care Veterinarians Name*
Clinic/Hospital Name*
How did you hear about us?*
Would you like to get updates and info from Violet Crown?

YesNo
VIOLET CROWN VETERINARY SPECIALISTS HOURS, APPOINTMENTS, AND PAYMENTS
HOURS: Our Specialty Departments' hours are Monday - Friday from 8am - 5pm. Our Emergency Department is open 24/7 including holidays and weekends for pets in need.

APPOINTMENTS: Violet Crown Veterinary Specialists (VCVS) makes every effort to see every appointment within a timely manner. Our Specialty Departments see patients on an appointment basis so that we can better plan and serve you. As it pertains to our Emergency Department, the most critical patients are seen first. Our goal is to be punctual and to have you in and out of our hospital for scheduled, routine appointments within 1 hour of your scheduled appointment time.

DROP OFF APPOINTMENTS: Drop Off Appointments vary based on Speciality Departments. Please ask a member of our staff about this appointment option.

PAYMENTS: Payment is due at the time of service unless otherwise discussed with the doctor or practice manager. For hospitalization, surgeries, and other procedures, 100% of the estimate is due before any services are rendered. If your pet is hospitalized, we will update your balance daily for payment in full. VCVS does not provide payment plans, although we do accept Care Credit, All Pets Card, ScratchPay, credit cards, and cash. VCVS does not accept payments by check.
CONSENT FOR VETERINARY TREATMENT & INTEGRATED OR ALTERNATIVE THERAPY
I am the owner or the agent for the owner of the patient described above, and I have the authority to execute this consent. I hereby consent and authorize Violet Crown Veterinary Specialists veterinarian/staff to perform examinations, diagnostic tests, radiographs, and medical and surgical treatments, including the administration of anesthesia, as determined to be necessary in the judgment of the licensed veterinarian supervising the care and treatment of the patient. I understand that I can request an estimate of anticipated expenses at any time and I can decline any treatment at any time.

I will not take home any medication, herbs, remedy, nutraceutical, and/or supplement that has not been fully explained to me to the point that I feel informed, to my satisfaction, by the veterinarian(s) or employees of VCVS.I also understand that no medication, herb, etc. can be returned after I have taken it from VCVS.

I HAVE FULLY READ THIS CONSENT FORM BEFORE SIGNING IT AND I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO ASK ANY QUESTIONS I HAVE UNTIL I FEEL FULLY SATISFIED PRIOR TO DEPARTMENT NOW OR AT ANY TIME IN THE FUTURE, WHETHER RELATED TO AN APPOINTMENT OR OTHER MEANS OF COMMUNICATION, REGARDING ANY AND ALL TRADITIONAL WESTERN OR INTEGRATED VETERINARY MEDICINE THERAPIES, RISKS ASSOCIATED WITH VETERINARIAN MEDICATION, OTHER ALTERNATIVE TREATMENTS, THERAPIES, AND PROTOCOLS OR PROCEDURES THAT ARE OR MAY BE AVAILABLE OR POSSIBLE FOR MY PET(S).
PHOTOGRAPHY, VIDEOGRAPHY, AND SOCIAL MEDIA RELEASE
Photographing, video recording, or audio recording in any way, patients, staff members, or any VCVS data, equipment, or property by clients, visitors, or others is prohibited. VCVS does reserve the right to use photographs, or video of your pet for education, promotional, or social media purposes. ALL images will be respectfully used and will not contain graphic or disturbing depictions.
If you do not wish your pet to be photographed or recorded please indicate here*

Yes, I allow VCVS to photograph and record my petNo, DO NOT photograph or record my pet
HARASSMENT AND ABUSE OF STAFF MEMBERS
Violet Crown Veterinary Specialists (VCVS) is committed to providing a safe working environment for our veterinarians, technicians, receptionists, and other employees. It is important to us that every member of our team feels comfortable, safe, and free from harassment of any kind. Harassment can take many forms. It may be, but is not limited to, the following: words, signs, jokes, pranks, intimidation, physical contact, or violence. Any of the listed actions are not tolerated and any persons in violation may be asked to leave the premises.

PAYMENT IS DUE IN FULL AT TIME OF SERVICE.

I HAVE FREELY AND KNOWINGLY READ BOTH SIDES AND SIGNED THIS CONSENT
Signature*

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DATE*

MonthDayYear
Date
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PERSON RESPONSIBLE FOR MEDICAL AND FINANCIAL DECISIONS REGARDING PATIENTS

OWNER INFORMATION

PATIENT INFORMATION

REFERRAL INFORMATION

VIOLET CROWN VETERINARY SPECIALISTS HOURS, APPOINTMENTS, AND PAYMENTS

CONSENT FOR VETERINARY TREATMENT & INTEGRATED OR ALTERNATIVE THERAPY

PHOTOGRAPHY, VIDEOGRAPHY, AND SOCIAL MEDIA RELEASE

HARASSMENT AND ABUSE OF STAFF MEMBERS