Date *

Owner's Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Spouse/Co-Owner

First

Last

Spouse/Co-Owner Phone

How would you like reminders? *

Email
Text
Phone

Number of pets (dogs, cats, other - please specify if other) *

Pet Health History

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Reason for visit *

Previous veterinary care provided by

Pet's current medications/preventatives

Vaccine history (please include dates)

Type of last vaccination

Diet *

Feeding schedule *

Snacks? *

Yes
No

How did you hear about us? *

If friend/family referral, who can we thank?

If other, please specify

Authorization

I hereby authorize the Veterinarian to examine, prescribe for and/or treat the above-described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that payment in full is required at the time that services are rendered and that a deposit may be required for surgical treatment. For your convenience, we accept all major credit cards, cash, personal checks, and CareCredit.

Respect Clause

We empathize that many circumstances requiring a visit to the veterinarian occur with stress, anger, fear, and frustration. Our patients and clients are of paramount importance to us, and we cherish them deeply. Our team is also dear to us and a valued part of the Monte Vista Animal Hospital family. We WILL NOT tolerate ANY abusive, threatening, or violent behavior towards our doctors or staff. We ask that clients conduct themselves with decorum and respect while in the hospital; anyone violating this policy will be discharged from our practice immediately. We also hold our team to the same standards of behavior.

Our hospital administrator, doctors, and team are always here to listen with open arms and open hearts and to address any issues that may arise.

Signature of Owner *

Date *

Photo Release *

I agree (yes)
I disagree (no)

We would love to feature your pet on our social media sites, website, or in our newsletter - but we need your permission! Please complete our photo release form so that we can take pictures to capture your pet's experience with our team. Don't worry, we will always let you know before posting a picture!

I am the owner/agent of the owner of the animal identified above, and do hereby consent and agree that Monte Vista Animal Hospital, its employees, or agents have the right to take photographs, videotape, or digital recordings of my pet and to use these in any and all media, now or hereafter known, and exclusively for the purpose of putting pictures of our patients on our website, social media, and within our newsletter. I further consent that my pet's name and identity may be revealed therein or by descriptive text or commentary. This consent remains in full force and effect unless and until I provide a written recovation of the consent. I do hereby release to Monte Vista Animal Hospital, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately. I waive any rights, claims or interest I may have to control the use of my pet's identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording my pet, either for initial or subsequent transmission or playback. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

Date *

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