Calusa Veterinary Center New Client Form

New Client Form
Owner Information
Name*

First NameLast Name
Spouse/Partner Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #*
Please enter a valid phone number.
Cell Phone #
Please enter a valid phone number.
Work Phone #
Please enter a valid phone number.
Email Address*
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Phone #
Please enter a valid phone number.
Caretaker/Pet Sitter Name

First NameLast Name
Caretaker/Pet Sitter Phone #
Please enter a valid phone number.
Caretaker/Pet Sitter authorized to treat pet?

YesNo
Owner's Initials
Do you have insurance for your pet(s)?

YesNo
If yes, name of insurance.
* Please provide our receptionist with a copy of your driver's license. *
Patient Information
Pet #1 Name*
Species
Breed
Color
Birthdate
Age
Sex
Vaccinated within the last year?

YesNo
Spayed/Neutered?

YesNo
Do you have another pet to add?

YesNo
Pet #2 Name*
Species
Breed
Color
Birthdate
Age
Sex
Vaccinated within the last year?

YesNo
Spayed/Neutered?

YesNo
Do you have another pet to add?

YesNo
Pet #3 Name*
Species
Breed
Color
Birthdate
Age
Sex
Vaccinated within the last year?

YesNo
Spayed/Neutered?

YesNo
Medical History
Please provide staff with a copy of your pet's records.

Cancelof
Referral Information
How Did You Find Us?

Drove ByFacebook/Social MediaGoogleYelpClientHumane/RescueFriends or FamilyEmployeeOther Hospital/DoctorOther
Who was the friend or family?
Which Client?
Which Employee?
Which other Hospital/Doctor?
ScribbleVet Consent and Release
Our veterinary services utilize ScribbleVet, a tool from Kairo Care, Inc., which records your pet's appointments for improved clinical documentation. We need your consent to proceed with the recording. By signing this agreement:

Appointment Recording: You agree that your vet appointments may be
recorded. If you don’t want to be recorded, let us know.

Usage Rights: You grant us permission to share these recordings, and any
other materials you choose to provide, for the purpose of improved clinical
documentation.

Age Confirmation & Understanding: You affirm that you are at least eighteen
years old, and that you understand and accept the terms in this agreement.

We are committed to providing the best care for your pet in a manner comfortable for both of you.
Signature of Owner for ScribbleVet Consent and Release *

Clear
Insurance Policy

It is the policy owner's responsibility to fill out and submit all forms for claims direction to your insurance company for payment to the policy holder.

If you are a pet health/medical insurance policy holder, we advise you to bring a blank insurance claim form, required by your company, to your appointment. Please ask your doctor to fill out the appropriate diagnosis and you should mail or fax your form back to your insurance company.

As a courtesy, one of our staff members will fill out your claim form for you, however, please allow 7-10 days for processing since we are dealing with a very heavy volume of insurance claims.
Payment Policy

A written/estimate treatment plan can br provided for your pet today upon requuest. All professional fees are due at the time services are rendered. We accept the following forms of payment: Cash, Personal Check, Visa, MasterCard, American Express, Discover and CareCredit.
Social Media & Website Permission: I give Calusa Veterinary Center permission to post my pet's photo on Calusa's Facebook page, website, printed media and other social media outlets.*

I ConsentI Decline
Initials*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Client Form

Owner Information

Patient Information

Medical History

Referral Information

ScribbleVet Consent and Release