Client Information Form

Thank you for scheduling a consultation for your pet's medical needs with Salt River Veterinary Specialists. Please complete the information below as best you are able. If you have questions regarding the information please do not hesitate to contact us to discuss in advance or at the time of your appointment.
Pet Owner Information
Has your pet previously been a patient of one of our Specialists before?
- Yes
- No
Owner*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone*
Secondary Phone
Email*
Co-Owner
First Last
Co-Owner Primary Phone
Co-Owner Secondary Phone
Co-Owner Email
Patient Information
Patient's Name*
Species
- Canine
- Feline
Breed
Age
Color
Sex*
- Male
- Female
- Neutered
- Spayed
Diet or brand feed
How often fed
When last fed
Referring/Regular Veterinarian
Referring Veterinarians
Name Hospital
Medical Information
Are your pet’s vaccinations up to date?
- Yes
- No
Year of last rabies vaccine
Please describe the current problem for which your pet is here
List medications being administered (including over-the-counter medications).
Name Dosage Frequency Duration

Please include dosage, frequency and duration that the medication has been administered to your pet
Has your pet had any allergies or drug sensitivities? If yes, please list medications and reaction
Has your pet ever had a previous surgery? If yes, please describe briefly
We love patient stories!
Do we have your permission to share your pet’s image and story on our social media and/or website? Your name and personal information will never be shared, we only use your pet’s first name.*
- Yes
- No
How did you hear about our hospital?
- My Veterinarian
- Friend
- Internet
- Magazine
Would you like to receive a copy of this form?
- No
- Yes
Services
I understand that payment in full is due at the time services are rendered. Should my pet need hospitalization, a prepayment will be required. (Payments may be made by cash, MasterCard, American Express or Visa.)
Patient Care Practice Policies
One of the most important criteria for the delivery of veterinary medical care from veterinarians and staff members at Salt River Veterinary Specialists is an understanding of our patient care practice principals. Please be aware of the following practice policies as a client of Salt River Veterinary Specialists to navigate your pet’s care in collaboration with us:
▪ Patient health outcomes are impacted by adherence to the care plan prescribed by our doctors. Compliance with medications, diet, monitoring lab work, and recommended follow-up appointments is an essential part of your pet’s care.
▪ It is imperative that there is mutual trust and respect between doctors, staff, and clients. Please maintain a respectful demeanor when communicating your needs and concerns to our staff. Disrespectful and inappropriate temperament will not be tolerated and will be grounds for dismissal from our practice.
▪ Our doctors dedicate their daily schedules to in-office appointments. Therefore, they may be unable to answer or return phone calls the same day. Our support staff works diligently with our doctors to address patient concerns as swiftly as possible but please understand same-day answers may not be possible due to emergent patients.
▪ Our doctors are unable to review follow-up lab work performed by an outside veterinarian after your initial consultation. We value the expertise of our colleagues and defer to their recommendations if they have ordered lab work for your pet. Recheck appointments are available for additional follow-up questions or concerns regarding lab work performed by an outside veterinarian.
▪ Salt River Veterinary Specialists is a specialty referral hospital, not an emergency clinic. We are not always able to arrange same-day urgent appointments once we reach capacity. Our doctor may need to refer your pet to an emergency clinic for urgent or emergency care when providing updates by phone regarding your pet’s status.
▪ Payment in full is due at the time services are rendered. Should your pet need hospitalization, a prepayment will be required (payments may be made by cash, Visa, Mastercard, American Express, Discover, CareCredit, or Scratchpay).
By signing below, you acknowledge you will adhere to Salt River Veterinary Specialists’ Patient Care Practice Policies.
Signature of Owner or Responsible Agent*
Date*
MM slash DD slash YYYY

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Name	Hospital

Name	Dosage	Frequency	Duration

Pet Owner Information

Patient Information

Referring/Regular Veterinarian

Medical Information

We love patient stories!

Services

Patient Care Practice Policies