Online Client Information Form

  1. (valid email required)
  2. (required)
  3. (required)
  4. (required)
  5. (required)
  6. (required)
  7. (required)
  8. (required)
  9. (required)
  10. (required)
  11. (required)
  12. PET HEALTH HISTORY
  13. (required)
  14. (required)
  15. (required)
  16. (required)
  17. AUTHORIZATION FOR EDUCATIONAL PURPOSES
  18. As leaders and teachers in the veterinary medical field, the specialists and staff of TBVSECC may use medical case information for teaching, developing forms, providing continuing education, website, veterinary literature development, social media updates, etc. I authorize the release of case/patient information for such purposes. Patient confidentiality (client names withheld) will be maintained.
  19. (required)
  20. AUTHORIZATION FOR FINANCIAL RESPONSIBILITY
  21. I am the owner of the above pet, or am acting as an agent for the owner. I accept full financial responsibility for professional and clinic fees, including the fees for medical, diagnostic and surgical procedures. I understand that this responsibility continues in the event that the patient fails to recover. I also understand that a deposit maybe required prior to hospitalization or procedure. All charges incurred to my pet are to be paid at the time of release or when services rendered. Additional charges will be incurred if follow-up examination, laboratory testing or extended telephone consultation is required pertinent to ongoing medical care. I have read the above statements, and I am fully aware of my responsibilities.
  22. (required)
 

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