Client Information

Owners Name

Primary Phone Number

Adress

City

State

Zip Code

New Patient Information

Reason for Visit

Patients Name

Species

Canine

Feline

Unknown

Sex

Male

Female

Neutered Male

Spayed Female

Unknown

Breed

Approximate DOB

Color

Is your pet microchipped

Yes

Unknown

Who is your regular or previous Veterinary Clinic

Is your pet aggressive with dogs, cats, or people

Yes

Unkown

Has your pet ever bitten anyone

Yes

Unknown

Has your pet had any previous vaccine reactions

Yes

Unknown

If yes, which vaccine

Does your pet have any allergies

Yes

Unknown

If yes, please describe

Treatment and Financial Authorization

I, the owner, or authorized agent, of the pet(s) listed above verify that I am at least 18 years of age and authorize Zia Pet Hospital (ZPH) to perform examinations and medical procedures on my pet(s), i.e. prescribing medications, hospitalization, sedation, anesthesia, and/or surgical procedures, as required for treatment of my pet. I understand that I can terminate treatment at any time by contacting doctors, technicians, or staff.

I understand that risk always exists with any treatments and that I am encouraged to discuss any concerns I have about those risks with the attending Veterinarian before any treatments or procedures are initiated. I understand that there is no stated or implied guarantee of successful treatment and that owner compliance and response to therapy determine if any further treatment is necessary along with associated costs.

I understand that any false information (i.e. contact information), failure to pay balances, or failure to pick up my pet without making prior arrangements with ZPH; my pet will be deemed “abandoned”. ZPH has full authority to do what is necessary for the care of your pet; including the transfer of your pet to the local animal shelter if needed.

I understand that patient confidentiality is maintained by our staff and medical information will not be released without approval from owners or authorized agents. Updates on patients in the hospital will be restricted to those listed as owners, co-owners, or authorized agents only. In the event that this animal transfers ownership, I authorize the release of medical information to the new owners, should they request it.

I, the owner or authorized agent, have read and understand that I am legally responsible for all financial obligations and agree to authorize treatment for my pet(s).

I, the owner or authorized agent, agree to the use of Talkatoo. This may include recording and transcribing of my pet’s appointment and future discussions regarding my pet’s care using Talkatoo’s technology. I am aware that Talkatoo does not store audio recordings or client personal information.

I, the owner or authorized agent, understand that this “Information and Photo Release” and “Treatment and Financial Authorization Form” will remain in effect indefinitely for the duration of my pet’s current and future veterinary care at Zia Pet Hospital. I can notify ZPH at any time and update the form, but THE OWNER MUST BE PRESENT.

Owners Signature

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