Name: Veterinarian
Brand: Zia Pet Hospital

Client / Owner Information

Reason for visit/concerns

Owners name (or agent)

Address

City/Town

State/Province

ZIP/Postal Code

Date

Please give us the best phone numbers to reach you (in order of importance)

Home

Cell

Work

Phone 1

Name

Choose

Home

Cell

Work

Phone 2

Name 2

Your Email

Secondary Email

Pet Information

Pet Name

Breed

Dog

Cat

Color

Sex

Spayed female

Neutered male

Un-spayed female

Unneutered male

Age/birthdate:

Who is your regular veterinarian (and/or clinic)?

I do not have a regular veterinarian

Is your pet aggressive with dogs, cats, or people?

Is your pet microchipped?

Yes

Unsure

Has your pet had any previous vaccine reactions?

Yes

Treatment and Financial Authorization

I hereby authorize that I am the owner, or authorized agent, of the pet(s) listed above 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 payment for the full balance is due upon discharge from the hospital. For all patient visits, an estimate can be provided prior. You may pay by cash, accepted credit cards, or CareCredit. WE DO NOT ACCEPT PERSONAL CHECKS. In order to avoid any misunderstandings, please let us know if you have any payment questions prior to services.

I understand that any false information (i.e. contact information), failure to pay balances, or failure to pickup 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 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, understand that this Treatment Authorization & Financial Authorization form will remain in effect indefinitely for the duration of my pet’s Veterinary present and future care at Zia Pet Hospital. I can notify ZPH at any time and update the form, but THE OWNER MUST BE PRESENT.

Information/Photo Release

ZPH maintains an internet presence for purposes including marketing and client education. Part of this presence includes photographs of our practice and its daily workings. Therefore, we may be interested in using images of your pet(s) and/or family as part of the effort to maintain, expand, and educate the public about our business and services, as well as include clients in every aspect of our practice. We may also use case information for purposes such as teaching, continuing education, website usage, and/or literature. I authorize the release of case/patient information for such purposes while patient confidentiality (names withheld) will be maintained.

Select one below:

I DO approve my pet’s case information and/or photos to be used while maintaining patient confidentiality.

I DO NOT approve my pet’s case information and/or photos to be used.

I, the owner or authorized agent, understand that this Treatment Authorization & Information/Photo release form will remain in effect indefinitely for the duration of my pet’s Veterinary present and future care at Zia Pet Hospital. I can notify ZPH at any time and update the form, but THE OWNER MUST BE PRESENT.

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