Desert Veterinary Medical Specialists (Peoria)

Owner Information Form

Thank you for the opportunity to care for your pet. So that we may become better acquainted, please complete the following information.

Owner

E-mail Address

Address

City

State

Zip

Owner Information

Primary Phone

Secondary Phone

Other Permissible Contact

Name:

Other Family Friend Pet Sitter Phone No.

Name:

Other Family Friend Pet Sitter Phone No.

Name:

Other Family Friend Pet Sitter Phone No.

(The above persons will be added to your account and have access to your pet’s medical information)

Primary Care Veterinarian

Doctor’s Name

Clinic Name

Referring Veterinarian (if different from above)

Doctor’s Name

Clinic Name

PET INFORMATION

Patient Name

Dog

Cat

Other

Breed

Color

Please choose one

Male/Intact

Male/Neutered

Female/Spayed

Female/Intact

DOB (or approximate age)

Reason for visit?

List any known drug allegeries

ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF THE VISIT.

We accept cash, all major credit cards, Care Credit, and check. A driver’s license is REQUIRED if you plan to pay by check. If you choose not to disclose this information, only cash or credit card will be accepted. There will be a service charge for any returned checks. A deposit is required at the time of admission and the balance paid in full at discharge. If you have any questions about the fees or the financial policy, please alert a front desk staff member before services are performed. Accounts not paid within 30 days are subject to an interest finance charge. In the event any balance due is not paid as agreed, the undersigned jointly and severally agrees to pay all costs included in the unpaid balance, including a reasonable collection and /or attorneys’ fee.

Arizona Veterinary Specialty Center is comprised of multiple practices within the building. Charges that are assessed for your pet will be billed separately through each appropriate practice. If you have any questions, please be sure to ask one of our front desk staff members.

Signature of Responsible Party (Must be over 18 years of age)

Date

Consent Form For Use Of Pharmaceuticals In Small Animals

The Food and Drug Administration (FDA) oversees the licensing of pharmaceuticals for humans and animals. Many drugs that have been approved for use in humans and/or some animals have also been proven to be safe and effective in species for which the drugs are not labeled. When drugs are FDA-approved for use in one species but are administered to species other than those for which they have been approved and labeled, the terminology is that the drugs are being used in an “extra-label” manner.

Extra-label use does not include the use of experimental drugs or drugs manufactured in foreign countries that have not been approved by the FDA. Despite this lack of FDA approval, it may be necessary to occasionally use such drugs when no other effective options exist.

Because few drugs are labeled for use in small animals, most drugs administered by small animal or exotic animal veterinarians, including antibiotics, anesthetic agents, and other medications, are routinely used in an extra-label manner. This is within the standard of care, but good medical practice requires that owners be advised when drugs are being used in an extra-label manner.

All drugs can potentially cause harmful side effects, including death. The drugs that will be used for your pet all have been safely used in individuals of the same or related species. When a drug must be used to treat an unusual disease or an unusual species, effectiveness and safety can be difficult to predict. You will be advised when your pet has been prescribed a medication that has not been given to a significant number of individuals of a similar species with a similar medical condition.You will be advised if an effective FDA-approved drug is not available and it becomes necessary to use a drug that has not been approved by the FDA to treat your pet.

Signature of Owner or Agent

Date

Please read and initial after each statement.

First and foremost please know that your pet's health and comfort is our primary concern. You are welcome to call at any time with questions or concerns. We look forward to helping you care for your pet. Emergencies may delay your appointment. We apologize for any inconvenience and ask for your understanding.

For prescription refills filled through our pharmacy please give us at least 24 hours notice. Refills requested Friday may not be filled until the following Monday. Any special orders need to be requested at least one week in advance. If your pet's prescription is filled through an outside pharmacy you should contact them first for refills, and they will contact us with questions or changes. We do not have the ability to refill any medications on the weekend.

Arizona Veterinary Emergency and Critical Care and other practices in the building are separate businesses and they do not have access to our pharmacy or our records. They will assist you any way they can but cannot fill medications for your pet on weekends or holidays.

All orders for pet food need to be placed by Friday, as we receive our food deliveries on either Wednesday or Thursday. We ask you to call first so that we may have your order ready. We keep only a limited food supply on hand. If you do not live in the area, or wish to have food delivered to you we suggest using Petfooddirect.com. We can provide you with written prescriptions for food if needed.

Lab results can take 2-10 days depending on the test that has been run. Some tests can take longer than others for final results. A technician will contact you when the final results have been received by our office and reviewed by the doctor. Fungal cultures can take up to 3 weeks for final results. We know that waiting for tests results can be stressful. Please be assured that we will call as soon as we have the results. If you are expecting a call and have not heard from us in a timely manner do not hesitate to contact us. You may realize sooner than us that there has been a delay at the lab.

If you have any questions regarding this form, please do not hesitate to ask. Thank you.

Release of Information for Media or Website Publication

Patient

Owner

Species

Breed

Desert Veterinary Medical Specialists would love to share your pet's story and educate you, your friends, your family, and the community about our company, the conditions that we diagnose, treat and conquer. We would like you to give us permission to release portions of your pet's medical history, personal recollections, radiographs, photographs, videotape images, and to use photographs or copies of letters, cards, or other gifts.

Your pet's information and photos may be used on a television or radio program, in the print media, in education lectures, on a brochure or on the website and all social media outlets of Desert Veterinary Medical Specialists and/or Arizona Veterinary Specialty Center for public education education and marketing purposes.

We hope that you will follow us on our social media sites and post pictures and stories of your own.

I, the undersigned, authorized to use my pet's information as outlined above.

Owner’s Signature

Date

I am over 21 years of age.

Yes

No

We also would like to be able to communicate with you via email. if you would like to receive information rom us, please let us know the best email address to use

Email