CLIENT MEDICAL REGISTRATION FORM Leave this field blank CLIENT NAME: PATIENT NAME: CLIENT PHONE: CLIENT EMAIL: CLIENT ADDRESS: SPECIES K9 FEL GENDER Male Female SPAYED/NEUTERED: Yes No BREED: BIRTHDATE/AGE COLOR: KNOWN ALLERGIES/MEDICAL CONDITIONS/MEDICATIONS: INSURANCE PROVIDER/POLICY#: ADDITIONAL NAME/S TO BE LISTED ON ACCOUNT: (optional) Spouse Partner Roommate Other NAME (optional) PHONE NUMBER: NAME/LOCATION OF PREVIOUS VET CARE: MAY WE CONTACT FOR RECORDS? Yes No PHONE NUMBER: HOW DID YOU HEAR ABOUT US? Facebook Google Search Yelp Referral Other PERSONAL REFERRAL? (optional) TREATMENT AUTHORIZATION and INFORMATION/PHOTO RELEASE (optional) I hereby authorize Roosevelt Station Vet Care (RSVC) to perform medical and initial diagnostic/surgical procedures on this animal as required for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctors and medical team. RSVC and it’s staff are leaders and teachers in the veterinary medicine field, thus case information and/or photos may be used in teaching forms and continuing education, website/social media, veterinary literature, and the like. I authorize the release of case/patient information for such purposes. FINANCIAL and PATIENT RELEASE POLICY (optional) Payment is due as services are rendered. The balance is due upon dismissal from the hospital. Payments can be made by cash, personal check (with proper identification), and accepted credit cards, including Care Credit. If payment arrangements are needed, the undersigned realizes that they must be agreed upon prior to admitting patients. In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory. In the event that I sell this animal to another owner, I authorize release of medical information to the new owner. DIGITAL SIGNATURE Please type your full name to indicate that you have read the above authorizations and policies. Submit
