Client Registration Form – Veterinarians in Oviedo, Florida

Client Information:

Name

First Last

Spouse/Partner Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Number:

Email

Preferred Contact Method:

Phone
Email

Discount Eligibility:

Are you over the age of 65?

Yes
No

Are you a U.S. Veteran?

Yes
No

Additional Authorization

Additional persons authorized to accompany my pet(s) at their appointments and/or make medical and financial decisions for my pet(s):

Name

First Last

Phone

Referral

I was referred by:

(We have a referral program and like to thank our clients!)

Pet Information

Pet’s name:

Species:

Breed:

Color/Markings:

Sex:

Female
Male

Neutered/Spayed?

Yes
No

Date of birth:

Microchip/Identification number:

Registered Through:

Previous Veterinarian:

Phone

Email

Any Known Allergies?

Yes
No

If yes, please describe:

Second Pet name:

Species:

Breed:

Color/Markings:

Sex:

Female
Male

Neutered/Spayed?

Yes
No

Date of birth:

Microchip/Identification number:

Registered Through:

Previous Veterinarian:

Phone

Email

Any Known Allergies?

Yes
No

If yes, please describe:

Third pet’s name:

Species:

Breed:

Color/Markings:

Sex:

Female
Male

Neutered/Spayed?

Yes
No

Date of birth:

Microchip/Identification number:

Registered Through:

Previous Veterinarian:

Phone

Email

Any Known Allergies?

Yes
No

If yes, please describe:

Additional pet name:

Species:

Breed:

Color/Markings:

Sex:

Female
Male

Information and Liability Release

Please check to indicate that you have read the following:

Consent*

I understand that Tuscawilla Oaks Animal Hospital is NOT a 24-hour facility and veterinarians and/or staff are not present during overnight hours when the hospital is closed.

Consent*

I understand that a fee of $60.00 will be charged for ANY one pet “no show” or canceled appointment without 24 hours’ advanced notice, $100.00 will be charged for ANY double pet "no show" or canceled appointment without 48 hour advanced notice. I understand that I may be subject to a $20 fee if I arrive 15 minutes late to my appointment and it may be rescheduled.

Consent*

I understand Tuscawilla Oaks Animal Hospital is a flea/tick free environment and if fleas/ticks are found on my pet upon entry/admission to Tuscawilla Oaks Animal Hospital that my pet will be given a flea and tick bath and/or Capstar, and I will be responsible for the associated costs.

Consent*

I understand that many of the medications that veterinarians prescribe for treatment may not be approved by the FDA (Food and Drug Administration) for all or any animal species and/or use may be considered “off-label.” However, it is a legal and well accepted practice for veterinarians to prescribe and use these medications in this manner. I understand this and if deemed necessary, I consent to the use of medications being administered “off-label” for treatment.

Consent*

I understand that animals respond individually and unpredictably to hospitalization, treatment and surgery. Tuscawilla Oaks Animal Hospital makes no guarantee as to any particular outcome of any patient’s case. I agree to release Tuscawilla Oaks Animal Hospital and its staff from all liability associated with hospitalization, treatment and surgery performed on my pet.

Consent*

I certify that I am over 18 years of age and assume full responsibility for all costs associated for services and/or treatments performed on my pets. Should my account become delinquent, I will be responsible for all collection costs, including, but not limited to the balance, attorney fees, court costs, collection agency fees and interest at the rate of 1.5% per month.

*

I consent
I do not consent

I understand that Tuscawilla Oaks Animal Hospital may take photographs/videos of my pet and use its medical information for teaching, veterinary literature, marketing and publishing. I authorize the release of my pet’s photographs for such purposes. Client privacy and medical confidentiality will be maintained.

Consent*

I understand that by law we are required to maintain accurate client and patient information and verify this information on a regular basis. This form needs to be fully completed and I will periodically be required to update specific information.

Consent*

I understand that all pet owners are required to communicate with team members and other pet owners in a kind and respectful manner.

Consent*

I understand that all dogs are required to be on a leash and all cats are required to be in a carrier or on a leash. Pet owners are responsible for the behavior of their pets. Please inform our team members if your pet has a history of aggression and/or severe anxiety.

Consent*

I understand that Tuscawilla Oaks Animal Hospital staff members are required to restrain all patients during examination and treatments for your safety and ours.

Consent*

I understand that it is required that a Provider Patient Relationship (PPR) in order to prescribe medications, provide diagnosis/treatment(s) or to participate in virtual health. To establish and maintain a PPR relationship, we require that the patient be examined at least once yearly. The PPR relationship can be terminated at any time by either Tuscawilla Oaks Animal Hospital or the pet owner.

Consent*

I understand that Tuscawilla Oaks Animal Hospital reserves the right to refuse service to anyone.

Deposits and Payments

For any and all medical care, service and/or treatment performed at Tuscawilla Oaks Animal Hospital, payment will be due at the time services/treatments are rendered. In addition, if your pet is hospitalized, 50% of the treatment plan will be collected as a deposit prior to admission and the balance to be paid upon hospital discharge. You may be asked to make additional payments towards your account if additional treatments are deemed necessary during hospitalization. A $75.00 deposit will be obtained in order to schedule ANY surgical or dental procedures performed by our veterinarians. A $100.00 deposit will be obtained in order to schedule any mobile specialist consultation or procedure.
We accept Cash, Visa, MasterCard, Discover and American Express along with third party funding, such as Care Credit (w/minimum of $200), Scratch Pay, etc.

Understanding/Acknowledgment/Agreement

My signature below indicates and acknowledges that I have read and fully understand and consent the policies and procedures as listed above by Tuscawilla Oaks Animal Hospital.

Signature of Pet Owner Or Authorized Agent*

Date*