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Pre-Registration
Name
(Required)
First
Middle
Last
Driver's License Number
(Required)
Additional Authorized Owner
(Required)
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Client DOB
MM slash DD slash YYYY
Primary Phone Number
This is a:
Home Phone
Cell Phone
Additional Phone Number
This is a:
Home Phone
Cell Phone
Email Address
(Required)
If not referred, how did you hear about us?
Google
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Sign/Location
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Other
Patient Information
Birth Date / Approximate Age
(Required)
Species
(Required)
Breed
(Required)
Sex
(Required)
Coloring
Alteration
(Required)
Spayed
Neutered
Intact
Unknown
Are vaccinations current?*
(Required)
Yes
No
Unknown
List Any Medications your pet is current taking
Has your pet seen any specialists? If so, who?
Veterinary Information
Name of Facility
Name of Referring Veterinarian
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone Number
Consent
I accept
I am the owner or authorized agent of the pet presented to Advanced Veterinary Internal Medicine. I am of legal age and I consent to the administration of emergency medical treatment for my pet in the best judgment of the veterinarian should the need arise. I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet and provide any pertinent medical records to other Veterinarians or medical professionals involved in my pet’s care unless requested otherwise. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid when services are rendered and that a deposit may be required for treatment. If for any reason payment is not made, I agree to interest charged annum, necessary attorney’s fees, court costs and late fees and any other recovery fees.
Consent
Yes, I authorize Pacific Care Pet Emergency & Specialty to use my pet’s first name, photograph and clinical information.
Pacific Care Pet Emergency & Specialty requests permission to use information for internal and external use such as: research, education and social media. I authorize the use of my pet’s first name, photograph and clinical information (including at times medical condition, treatment and prognosis). Under no circumstances will my name, my personal or financial information be shared through these sources.
