Patient Registration Form

Thank you for giving us the opportunity to care for your pet. To ensure the best care possible, please take the time to fill out this form completely.

Thank you!

GENERAL INFORMATION

Client Name

Patient Name

Spouse/Partner Name

DOB/Age

Alternate / Guardian

Vaccine / Status

Address

Species

Primary Phone

Breed

Secondary Phone

Sex

Client Email

Employer Name

Insurance?

Yes No

Spayed/Neutered?

Yes No

Authorization:

I accept that all procedures will be performed to the best of the abilities of the staff at Veterinary Dermatology & Ear Referral Medical Clinic. I understand that no guarantee or warranty has been made regarding the results that may be achieved. I understand that I assume financial responsibility and will pay for all services upon my pet’s discharge from Veterinary Dermatology & Ear Referral Medical Clinic.:

Authorization Signature:

Veterinary Dermatology & Ear Referral Medical Clinic, its representatives and employees have my permission to photograph my pet for the purpose of documenting treatment progress. I also permit the use of said photographs and case information for educational purposes, copyright, use, and publish the same in print and/or electronically. I agree that Veterinary Dermatology & Ear Referral Medical Clinic may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. Confidentiality is assured and all other personal information will remain in confidence.

Permission Signature

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Patient Registration Form

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