Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Mobile Phone

Home Phone

Address *

City *

State *

Zip Code *

Employer

Occupation

Date of Birth *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

By listing your primary care veterinarian, you are authorizing Pacific & Santa Cruz Veterinary Specialists to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

By submitting this form, I hereby authorize Pacific & Santa Cruz Veterinary Specialists to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Pacific & Santa Cruz Veterinary Specialists.

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