Client and Patient Information FormClient InformationPlease provide the following information about yourself, the pet owner. All fields labeled with an asterisk (*) are required.Owner's Name*Spouse/Partner's NameHome Address*City, State*ZIP Code*Best Contact Phone Number*Cell Phone NumberHome Phone NumberAlternative Phone NumberEmail Address*Preferred Method of Communication:*Please SelectEmailPhone CallTextEmployerWork Phone NumberOwner's DOB*Driver's License NumberDriver's License StateDriver's License Expiration DateMM/YYPatient (Pet) InformationPlease provide the following information about the patient, your pet. All fields labeled with an asterisk (*) are required.Pet's Name*Sex* Male Female Breed*Neutered/Spayed?* Yes No Color*Age*Weight*Reason for your visit today:*Has your pet had labwork done for this issue?* Yes No Has your pet had x-rays done for this issue?* Yes No Primary Veterinary Hospital Name*Has your pet been seen anywhere else?* Yes No Additional Hospital(s)*Please list the name(s) of the other hospitals at which your pet has been seen. We will communicate with the veterinarian(s) listed above regarding your pet’s condition.How did you hear about us?* Veterinary Referral Friend/Breeder Yelp Google Other Specialists Referring Hospital and Veterinarian InformationSignaturesPlease read and agree to the terms, then sign and date below.I am of legal age. I am the owner or authorized agent of the pet(s) presented to AVSG Internal Medicine & Urgent Care. I understand that an initial examination will be performed, and a verbal or written estimate will be provided to me before any other services are rendered. I assume financial responsibility for all professional fees and agree to pay at the time services are rendered. If for any reason payment is not made, I agree to interest charged per annum, necessary attorney’s fee, court costs, late fees, and any other recovery fees.* I Agree I understand that AVSG Internal Medicine & Urgent Care consists of leaders and teachers in veterinary medicine, thus case information and/or photos may be used in teaching, documentation, continuing education, their website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; patient confidentiality will be maintained unless otherwise authorized.* I Agree The cost for the Internal Medicine initial consultation is $210. The cost for the Urgent Care initial consultation is $120. I understand that the minimum cost of this appointment is $210 or $120 respective to the associated department and I agree to pay in full for this and any other services that I have agreed to at the time of the consultation.* I Agree Owner/Authorized Agent eSignature* First Last Date* Month Day Year CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
