CLIENT INFORMATION

CLIENT INFORMATION
NAME:
Name
First NameLast Name
CO OWNER
OWNER D.O.B
ADDRESS
APT#
CITY
STATE
ZIP
PHONE NUMBER#
EMERGENCY #
HOW DID YOU HEAR ABOUT US?
PLEASE PROVIDE US WITH AN EMAIL ADDRESS, SO YOU WILL ALWAYS HAVE ACCESS TO YOUR PETS MEDICAL RECORDS.
EMAIL:
example@example.com
PET INFORMATION
PET #1 NAME:
SPECIES
OTHER
Gender
BREED
COLOR
DOB/AGE
VACCINES UPDATED
WE WILL GLADLY PREPARE A WRITTEN ESTIMATE IF YOU DESIRE. THIS IS IMPORTANT, AS ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. I UNDERSTAND THAT ALL FEES ARE DUE AT THE TIME OF MY PETS RELEASE AND A DEPOSIT IS REQUIRED. I AUTHORIZE SOUTH BAY VET HOSPITAL TO PROVIDE CARE FOR MY PETS. I ASSUME RESPONSIBILITY FOR ALL CHARGES ON THIS ACCOUNT. I GRANT TO OUR PET VETS, ITS REPRESENTATIVES, THE RIGHT TO TAKE PHOTOGRAPHS/ VIDEOS OF ME AND OR PET. I AGREE THAT OUR PET VETS MAY USE SUCH PHOTOGRAPHS OF ME AND/OR PETS WITH OR WITHOUT MY NAME AND FOR ANY LAWFUL PURPOSE, INCLUDING, FOR AN EXAMPLE SOCIAL MEDIA OR WEB CONTENT. (PLEASE INITIAL)
THE ABOVE MAY
OR MAY NOT
SIGNATURE OF OWNER/AGENT____________________________________ DATE
SIGNATURE OF OWNER/AGENT
Clear
DATE
MonthDayYear
Date
CONTROLLED SUBSTANCES AUTHORIZATION FORM
DR. ON STAFF
The following agreement relates to your pet’s use of a controlled substance prescribed by a licensed veterinarian at South Bay Vet Hospital.
Cures is a database of schedule II-VI controlled substances prescribed in the state of California. It was established by the Drug Enforcement Agency and Department of Justice in 2006 to reduce prescription drug abuse and diversion without affecting legitimate medical practice or patient care. Ca. law (Health and Safety Code 11165.1) requires us to report all controlled substances dispensed and provide specified dispensing information to the Department of Justice on a weekly basis.
If the licensed veterinarian recommends a controlled substance for you pet’s condition, these regulations must be met: 1.Owner’s Date of Birth must be provided. (Must be older than 18 years old) 2.By law, a maximum of thirty days supply of medicine will be prescribed at any one time
Pet Name:
Owners Printed name:
Owner's Signature:
Clear
Owner's Date of Birth:
MonthDayYear
Date
Name
First NameLast Name
Should be Empty:

CLIENT INFORMATION

NAME:

PET INFORMATION

SIGNATURE OF OWNER/AGENT____________________________________ DATE

CONTROLLED SUBSTANCES AUTHORIZATION FORM