Preventive Care Plans for Cats Form

Full Name(Required)

First Last

E-mail(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone Number(Required)

Is your Primary Phone Number a cell phone?(Required)

Yes
No

I prefer to be contacted via (select all that apply):(Required)

Text message
Phone call
E-mail

Alternate Phone Number

Is your Alternate Phone Number a cell phone?

Yes
No

Name of Spouse/Significant Other:

First Last

How did you first hear about us?(Required)

Were you referred to us by a family member, friend, or acquaintance? If so, whom should we thank?

Employer

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact

First Last

Emergency Contact Phone Number

Please indicate your preferred method(s) of payment:

Cash
Credit/Debit Card
Care Credit
Scratchpay

Driver's License Number & State

Date of Birth(Required)

What are your top expectations of your veterinary team?(Required)

Please list all of your pets' names, species, breed, age, sex, and whether or not your pet(s) are neutered/spayed:(Required)

Has your pet received veterinary care in the past? If yes, please list your previous clinic's name and phone number so that we may call and have records faxed or e-mailed to us.(Required)

This allows us to determine what your pet is due for before your appointment and enables us to be more efficient with your time as well as ours.

Do you grant the Animal Care Clinic and its representatives permission to take photographs of you, your family, and/or your pet(s) and publish the same electronically, including, for example such purposes as website content, publicity, and/or social media?(Required)

Yes
No

I hereby authorize and request the Animal Care Clinic to release medical information concerning the aforementioned pet(s) to the following individuals or organizations:(Required)

I have read the above information and authorized the Animal Care Clinic to disclose the identified information to the persons described herein. I understand that by signing this document, I release and discharge the Animal Care Clinic from liability and will hold Animal Care Clinic harmless for any release made pursuant to this authorization.(Required)

I agree

We will gladly prepare a written treatment plan with estimated prices if you desire. Please ask a team member. All professional fees are due at the time of services rendered. A deposit prior to treatment may be required depending upon the amount of the estimate. To prevent the spread of infectious diseases and parasites, all hospitalized patients must be current on all required vaccines and must be free of internal and external parasites.(Required)

I understand

As the responsible owner or owner’s agent for the pet(s) being presented to this facility, and agreeing to abide in full by the above stated hospital policies, I hereby consent and authorize the Animal Care Clinic to receive, prescribe for, treat, or operate upon my pet(s). As a client of the Animal Care Clinic, I understand that the practice’s basic philosophy is to tell me what my pet needs to remain healthy and protected from disease. I also understand that I have the right to waive my pet’s rights to the level of care being offered by the veterinarian and assume the responsibility and liability that I place my pet into such action. I understand that the Animal Care Clinic is not staffed 24 hours daily. If my pet is hospitalized for overnight treatment with Animal Care Clinic, and if intensive care or observation is warranted or advisable, the veterinarian will either perform these services, or in the event that she is unable to do so, your pet will be referred for the night to an emergency clinic that is fully staffed during that time. I authorize the doctor to provide vaccines and parasite control as needed for my hospitalized pet(s) at my expense (if required) in accordance with the above stated hospital policy. Should an emergency situation arise, I authorize the veterinarian to do whatever is necessary, to include tranquilization as required. I understand that I assume complete financial responsibility for all services rendered, and that payment is due in full at the time of completion of services rendered, or upon release of the patient from our facility unless otherwise arranged in advance.(Required)

I agree

Signature

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Preventive Care Plans for Cats Form

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