Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Our reminder system is done via a third-party: Pet Health Network will send messages via text and email regarding upcoming appointments and/or reminders. Please initial here if you wish to OPT OUT of the reminder system.

We will sometimes post pictures of our patients to social media and/or for internal use/slideshow. Please initial here if you wish to OPT OUT

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Has your pet had vaccines within the year?

Yes
No

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Previous Medical Problems

Yes
No

Current Medications

Allergies/Drug reactions

Yes
No

Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your Pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept Cash, Visa, MasterCard, Discover, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

Date *

Date of Birth of Owner *

Rancho San Carlos Pet Clinic, by law, asks for your date of birth in order to legally prescribe controlled substance prescriptions for your pet if deemed necessary by a Veterinarian. This information is kept confidential and exclusively used for providing the dispensing information to the Department of Justice. “Pursuant to Business and Professions Code Section 4170 and Section 11190 of the Health and Safety Code, all licensees who dispense Schedule II, III and IV controlled substance must provide the dispensing information to the Department of Justice on a weekly basis.” - Veterinary Medical Board of California

Print Name *

Date *

I authorize the release of my pet(s) previous medical records to Rancho San Carlos Pet Clinic Signature of Owner/authorized agent *

Clear Signature