SCVH New Client Registration

Thank you for choosing to partner with Santa Cruz Veterinary Hospital when seeking the best care for your companion(s).

Santa Cruz Veterinary Hospital is a full-service, small animal veterinary hospital. We are committed to providing personal, comprehensive care to each patient and client through companion animal medical, reproductive, surgical, and dental services.

Top quality patient care is one of our highest priorities, as is respecting the relationship between you and your pet. We treat your pet as we would our own. Our doctors and support staff are committed to providing personal attention to the unique concerns of each pet owner. As your companion(s)'s health care partner, we strive to help you make informed and compassionate choices for their care.

Our small animal surgery and dental services emphasizes client education alongside compassionate patient care. While low stress, and fear-free, practices work to create a healthful environment for your pet(s)'s medical experiene and rehabilitation.

Owner's Name: *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Email *

example@example.com

Phone Number *

Area Code Phone Number

Preferred Method of Contact *

Marital Status *

Single Married Divorced Widowed

Owner's Date of birth: *

Day Month Year

Partner or other authorized agents name:

First Name Last Name

Additional person's relation to you

Additional person's phone number:

Area Code Phone Number

Do you authorize the above provided Partner/Co-Owner to make urgent decisions if you are unreachable?

Yes No

Preferred Veterinarian *

Current Pet Insurance Provider

Upload Blank Insurance Form

Pet's Name: *

Pet's Age/Date of Birth:

Type of Pet *

Canine Feline

What Breed and Color is your Pet? *

Pet's sex:

Male Female Neutered Male Spayed Female

Do you have additional Pets?

Yes No

Pet's Name: *

Pet's Age/Date of Birth:

Type of Pet *

Canine Feline

What Breed and Color is your Pet? *

Pet's sex:

Male Female Neutered Male Spayed Female

Previous Veterinarian's Name

Initial Presenting Problem/ Special Needs/ Concerns:

Consent

I, the undersigned owner or agent of the owner, hereby consent to the examination of my pet by Santa Cruz Veterinary Hospital (SCVH). I agree that after consultation with me, the hospital's Doctors may prescribe medication for, treat, hospitalize, anesthetize and.or perform surgery on my pet. I understand that no guarantee can be made as to the outcome of treatment and that I am encouraged to discuss any concerns I have about the risks of treatment with the attending Veterinarian before any procedures or treatment is initiated.

I understand that a treatment plan including an estimate of the costs for Veterinary Services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during my pet's ongoing medical treatment.

I hereby authorize the name(s) above to make financial and medical decisions for the patient listed. I understand the professional fees are to be paid at the time services are rendered and a deposit is required on all pets admitted to the hospital.

I understand that I (the owner or agent) am financially responsible to SCVH for all charges relating to this patient. I have read and agree to the treatment authorization. I have also read and accept the financial obligations.

Signature *

Clear

Welcome

New Client Registration

Patient Information