Client Information

Owner's Name *

First Name

Last Name

Spouse/Partner's Name

First Name

Last Name

Home Address *

Street Address

Street Address Line 2

City

State

Zip

Best Contact Phone Number *

Cell Phone Number

Home Phone Number

Alternative Phone Number

Email *

Preferred Method of Communication *

Employer

Work Phone Number

Owner's Date of Birth *

Driver's License Number

Driver's License State

Driver's License Expiration Date

Patient (Pet) Information

Pet's Name *

First Name

Last Name

Sex *

MaleFemale

Breed *

Neutered/Spayed? *

YesNo

Color *

Age *

Weight *

Reason for your visit today? *

Has your pet had labwork done for this issue? *

YesNo

Has your pet had x-rays done for this issue? *

YesNo

Primary Veterinary Hospital Name *

Has your pet been seen anywhere else? *

YesNo

How did you hear about us? *

Signatures

Please read and agree to the terms, then sign and date below.

I am of legal age. I am the owner or authorized agent of the pet(s) presented to AVSG Internal Medicine & Emergency/Critical Care. I understand that an initial examination will be performed, and a verbal or written estimate will be provided to me before any other services are rendered. I assume financial responsibility for all professional fees and agree to pay at the time services are rendered. If for any reason payment is not made, I agree to interest charged per annum, necessary attorney’s fee, court costs, late fees, and any other recovery fees.

I agree *

I agree

I understand that AVSG Internal Medicine & Emergency/Critical Care consists of leaders and teachers in veterinary medicine, thus case information and/or photos may be used in teaching, documentation, continuing education, their website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; patient confidentiality will be maintained unless otherwise authorized.

I agree *

I agree

The cost for the Internal Medicine initial consultation is $266. The cost for the Emergency Care initial consultation is $194. I understand that the minimum cost of this appointment is $266 or $194 respective to the associated department and I agree to pay in full for this and any other services that I have agreed to at the time of the consultation.

I agree *

I agree

Owner/Authorized Agent eSignature *

Date *

Client Registration

AVSG Internal Medicine Emergency & Critical Care

Client Information

Patient (Pet) Information

Signatures