Form test | City Veterinary Care

Client Information

Full Name*

First Name Last Name

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.

Pet Information

Pet's Name*

Species*

Dog

Cat

Breed*

Sex*

Male

Female

Is your pet spayed / neutered?*

Yes

No

I don't know

Color / Markings*

Date of Birth*

Please estimate Month & Year if you aren't sure

Is your pet microchipped?*

Yes

No

I'm Not sure

If yes, what is the Microchip Number?

Please upload any previous medical records.

Max. file size: 15 MB.

Please list all veterinary facilities previously visited.

I give permission for City Veterinary Care to contact previous veterinary facilities for records pertaining to this patient.*

Yes

No

Please upload a picture of your pet

Max. file size: 15 MB.

Pet Insurance Company and Policy ID (if applicable)

Financial Responsibility Agreement

Payment for all services and medications is due at the time they are rendered. Due to high operating costs, we are unable to carry balances on accounts.

We accept Cash, Check, Visa, Mastercard, Discover & American Express.

Cancellation Policy

There is a fee of $50.00 for Same-day cancellations and No Show appointments.

I understand that I am financially responsible for all charges at the time they are rendered. I give permission for City Veterinary Care to automatically charge my card on file for any and all open invoices/balances I incurred. I agree that, in the event of non-payments, I will bear the expense of all collection and/or legal fees, should I fail to honor this agreement. I certify that I am 18 years of age or older.

Full Name*

First Name Last Name

Signature

Veterinary Medical Records Release

In accordance with the Veterinary Practice Act set forth by the AVMA regarding the confidentiality of patient medical records, a written authorization or written documentation of a waiver via the client’s verbal consent is required in order to produce copies of your pet(s)’ medical records.

Select one:*

I, the undersigned, am the owner or authorized agent for the owner of the pet(s) listed below, request and give my permission to release the medical records for my pet(s) to any other veterinary hospitals, emergency hospitals, groomers, and/or daycare/boarding facilities that request them. I agree that this agreement will remain in effect until an official letter is received from me, the owner. I understand that I must give either a written or verbal authorization for my medical records to be released to anyone other than the exceptions listed previously.

I respectfully decline and wish to be contacted should anyone request any information regarding my pet(s). NOTE: Should you request to deny this release form please note that you will be contacted each and every time prior to any of your pet(s) medical records being released to anyone not already listed/authorized in your account.

List All Pet Names*

Signature*

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Client Information

Pet Information

Financial Responsibility Agreement

Veterinary Medical Records Release

Hours of Operation:

In Case of Emergency: