Owner's Name *

First

Last

Please list who can make an appointment, authorize treatment, or make a payment. List their name and their relationship to you, please!

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary Contact Name *

Primary Phone Number *

Primary Phone Type *

Home
Cell
Work

Secondary Contact Name

Secondary Phone Type

Home
Cell
Work

Secondary Phone Number

Secondary Contact Relationship *

Secondary Contact Relationship

Preferred Contact Method *

Call
Text
Email

Owner's Date of Birth *

California state law requires us to have our client's date of birth to dispense certain types of medications, such as pain relievers, and sedatives. You must be 18 years or older to complete this form.

Tell Us About Your Pet

Pet's Name *

Species/Breed *

Pet's Age *

Please specify your pet's age *

Months
Years

Major Colors *

Sex *

Spayed/Neutered? *

Has this pet received care at another veterinary clinic? *

Yes
No

If yes, please specify where: *

Would you like to add another pet? *

Yes
No

Patient's Name *

Species/Breed *

Age *

Please specify your pet's age *

Months
Years

Major Colors *

Sex *

Spayed/Neutered? *

Has this pet received care at another veterinary clinic? *

Yes
No

If yes, please specify where: *

Would you like to keep the listed veterinarian(s) informed about your visit(s) with us? *

Yes
No

Would you like to add another pet? *

Yes
No

Patient's Name *

Species/Breed *

Age *

Please specify your pet's age (copy) *

Months
Years

Major Colors *

Sex *

Spayed/Neutered? *

Has this pet received care at another veterinary clinic? *

Yes
No

If yes, please specify where: *

How did you hear about us? *

Please list clinic’s name *

If other, please specify *

If friend, please specify. *

Treatment Consent

Please read and initial the following statements. Our staff will be happy to explain any of these statements prior to your initialing.

I, the undersigned, do hereby certify that I am over the age of 18 and am the owner or authorized agent of the above-described patient. I authorize the Exotic Pet Clinic of Santa Cruz and its employees to receive, examine, prescribe for, and treat the above-described pet. I further understand that no guarantee of successful treatment is made, and I will not hold Exotic Pet Clinic of Santa Cruz or its employees responsible for my pet's recovery. *

Yes, I certify

I am aware that all diagnostics, treatment, and medication charges are in addition to any examination fee. I understand that payment is DUE IN FULL at the time of service. If my account becomes delinquent, I understand that it may be turned over to a collection agency and that I will be responsible for all service charges, court costs, collection fees, and reasonable attorney's fees. *

Yes, I authorize to pay

I understand that the Exotic Pet Clinic of Santa Cruz is not a 24-hour facility and that personnel will not tend to patients overnight. I understand that I can request transfer to an emergency veterinary hospital with 24-hour care if overnight hospitalization is required. *

I understand there is no overnight staff

Exotic Pet Clinic of Santa Cruz is part of your pet's continuum of care, and we may provide your family veterinarian and other veterinary specialists with information regarding your pet's treatment or condition. By signing below, you are authorizing Exotic Pet Clinic of Santa Cruz to share your pet's medical record with a third party (such as your family veterinarian or a veterinary specialist) as necessary for us to provide continuous veterinary care to your pet. You agree that we may send you communications to your contact information provided above regarding your pet. *

Yes, I authorize

We love social media! Do we have your permission to share stories and images of your pet(s) on social media, our website, or other related forms of media? Your name and personal information will never be shared.  *

Yes
No

I am the owner or the authorized agent for the owner of the pet(s) described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age and that I have read and understood the above information.

Signature *

Please type your name out. *

Date *

We have Rabbit Hemorrhagic Disease vaccines in stock!

New Client Form

New Client Form

Tell Us About Your Pet

Treatment Consent

Contact Us

Questions?

Contact

Hours

Location