Roosevelt Station Vet Care

CLIENT MEDICAL REGISTRATION FORM

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CLIENT/OWNER NAME: *

PHONE: *

PATIENT/PET NAME: *

EMAIL: *

ADDRESS: *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

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SPECIES *

• K9
• FELINE

BIRTHDATE/AGE *

GENDER *

• Male
• Female

BREED:

SPAYED/NEUTERED: *

• Yes
• No

COLOR *

KNOWN ALLERGIES / MEDICAL CONDITIONS / MEDICATIONS

INSURANCE PROVIDER / POLICY#

ADDITIONAL NAME(S) TO BE LISTED ON ACCOUNT (optional)SpousePartnerRoommateOther

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NAME (optional)

PHONE (optional)

NAME / LOCATION OF PREVIOUS VET CARE

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MAY WE CONTACT FOR RECORDS?

• Yes
• No

HOW DID YOU HEAR ABOUT US?GoogleYelp ReferralOther

PHONE

WHO SHOULD WE THANK IF REFERRED?

TREATMENT AUTHORIZATION and INFORMATION/PHOTO RELEASE *

PLEASE TYPE YOUR FULL NAME IN THE BOX ABOVE TO INDICATE THAT YOU HAVE READ THE AUTHORIZATIONS AND POLICIES.

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 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.

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