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

VSSOC and AVSG IMERCC seek to continually provide a welcoming and safe environment ensuring trust and respect for all people and pets. We have a zero tolerance for the use of threatening or aggressive behavior, abusive language, and threats of physical harm or violence. Words or actions that are disrespectful, racist, discriminatory, hostile, or harassing will not be tolerated. In the event that your behavior is problematic, we reserve the right to discontinue services immediately and you will be asked to leave the facility. I understand and abide by the code of conduct.

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