Please list who can make an appointment, authorize treatment, or make a payment. List their name and their relationship to you, please! Email * Primary Phone Contact Name * Primary Phone * Secondary Phone Contact Name Secondary Phone Secondary Contact Relationship Preferred Contact Method * Owner's Date of Birth * DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM 1 2 3 4 5 6 7 8 9 10 11 12 YYYY 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
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 * Major Colors * Sex * Spayed/Neutered? * Has this pet received care at another veterinary clinic? * If yes, please specify where: * Would you like to add another pet? * Patient's Name * Species/Breed * Age * Please specify your pet's age * Major Colors * Sex * Spayed/Neutered? * Has this pet received care at another veterinary clinic? * If yes, please specify where: * Would you like to keep the listed veterinarian(s) informed about your visit(s) with us? * Would you like to add another pet? * Patient's Name * Species/Breed * Age * Please specify your pet's age (copy) * Major Colors * Sex * Spayed/Neutered? * Has this pet received care at another veterinary clinic? * If yes, please specify where: * How did you hear about us? * Google search Facebook Friend or family member Other veterinary clinic My pet has seen Dr. Stern at other clinics Other Please list clinic’s name * If other, please specify * If friend, please describe. If Pet Store, please describe. If Veterinarian, please describe. If internet, from where? 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. * 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. * 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. * 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. * 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.
* 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. Please type your name out. *