Contact Information
Primary Contact Name
(Required)
Primary Contact Phone Number
(Required)
Primary Contact Email Address
(Required)
Secondary Contact Name
Secondary Contact Phone Number
Address
(Required)
City
(Required)
STATE
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
(Required)
Hidden
Preferred Method of Contact
(Required)
Please Select
Email
Text / SMS
Phone Call
Preferred Method of Contact
(Required)
Email
Phone Call
Text / SMS
Pet Information
Patient's Name
(Required)
Date of Birth / Estimated Age
(Required)
Breed
(Required)
Spayed/Neutered
(Required)
Yes
No
Gender
(Required)
Female
Male
Pet Information - below please indicate your primary concern for today's visit: (i.e vomiting/diarrhea/ lameness)
(Required)
About Us
How did you hear about us?
Family/Friend (please indicate below)
Internet search
Facebook/Instagram/Social Media
Primary Veterinarian
Other (please indicate below)
Family/Friend
Other
Do you currently use a primary care veterinarian, specialty vets, or have any other affiliations you'd like us to know about?
Photograph and Video Release: There may be times we would like to share a photo or video of your pet with our social media sites (including but not limited to our website, Facebook, Instagram, etc.) Please indicate your wishes below:
(Required)
I hereby grant permission to use my pet(s) photograph or video on social media, website, promotional materials, etc, without compensation. Materials will become the property of the hospital.
I decline the use of my pet(s) photograph or video on any social media, website, promotional materials, etc.
Notification Settings - We use text messages and email to communicate appointment reminders, as well as your pet's health reminders (vaccines, exams, etc), and occasional emergency closure notices. If you would like to opt OUT of these reminders, please indicate below.
I consent to text and email notifications at the above primary cell number and email.
I consent to email notifications ONLY.
I consent to text notifications ONLY. I am aware I will not receive my pet's reminders and will need to use the PetPortal to see when they are due for services.
I decline both email and text notifications. I am aware I will not receive my pet's reminders and will need to PetPortal to see when they are due for services..
I,
, the undersigned, am the owner or agent for the owner of the animal(s) described, and I have the full and exclusive authority to execute this consent.
I certify that I am 18 years of age or older.
I give permission to doctors, staff, authorized agents, or representatives of this hospital to examine, prescribe for, and treat my pets.
I agree to pay for all services rendered and medications, goods, and supplies when purchased.
I understand that all fees are due at the time services are rendered and the hospital accepts cash, check, and all major credit cards.
I understand that a deposit may be required for surgical or medical treatment.
I understand that if my pet ever requires overnight hospitalization, there will not be overnight supervision provided.
I release this hospital from any and all liabilities.
By my signature below, I hereby acknowledge that I agree to all of the above and acknowledge the receipt of a copy of this agreement upon request.
Owner/Agent Name
June 15, 2025
Signature