Owner Information

Owner First & Last Name *

Co-Owner First & Last Name *

Address *

City *

State *

Zip Code *

Email *

Primary Contact Phone *

Secondary Contact Phone *

Additional Contact Phone

Are you 18 Years of age or older? *

Yes

No

Patient Information

Pet Name *

Reason For Visit *

Species *

Sex *

Birth Date / Estimated Age *

Breed *

Color

Primary Veterinary Clinic *

Please list any medications your pet is currently taking: *

Authorization

I give consent to the veterinarian to examine, treat and prescribe medication for the pet(s) listed above. *

I Agree

I understand that Veterinary Specialty Center of Tucson takes 100% of the high end of the Treatment plan prior to any services provided. *

I Agree

I understand that ALL charges incurred in the treatment of my pet must be paid in full at the time of discharge. *

I Agree

I understand that I am responsible for ALL charges authorized by me or the co-owner of my pet. *

I Agree

I understand that I am expected to treat all staff members of Veterinary Specialty Center of Tucson with respect and courtesy or I may be dismissed from the practice. Rude, vulgar, and unprofessional conduct are not tolerated under any circumstances. *

I Agree

I understand that failure to communicate with Veterinary Specialty Center of Tucson for longer than 24 hours will be considered pet abandonment and my pet will be relinquished to PACC or the Humane Society. *

I Agree

I understand that if I request medical records for my pet, there is a 7-10 day processing time. *

I Agree

I have read, understand and agree with terms outlined above. *

Yes

Signature Of Owner *

Date *

By submitting this form, I hereby authorize Veterinary Specialty Center of Tucson to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Veterinary Specialty Center of Tucson.

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New Patient Form

Owner Information

Patient Information

Authorization

Emergency Care 7 Days a Week

New Patient Form

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New Patient Form

Owner Information

Patient Information

Authorization

Emergency Care 7 Days a Week

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OPTION 2
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