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 InformationHas your pet previously been a patient of one of our Specialists before? Yes NoOwner* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Phone*Secondary PhoneEmail* Co-Owner First Last Co-Owner Primary PhoneCo-Owner Secondary PhoneCo-Owner Email Patient InformationPatient's Name*Species Canine Feline BreedAgeColorSex* Male Female Neutered SpayedDiet or brand feedHow often fedWhen last fedReferring/Regular VeterinarianReferring VeterinariansNameHospital Medical InformationAre your pet’s vaccinations up to date? Yes NoYear of last rabies vaccinePlease describe the current problem for which your pet is hereList medications being administered (including over-the-counter medications).NameDosageFrequencyDuration Please include dosage, frequency and duration that the medication has been administered to your petHas 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 brieflyWe 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 NoServicesI 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.)Code of ConductOne of the most important criteria for the delivery of veterinary medical care from veterinarians and staff members at Salt River Veterinary Specialists is a polite, effective, comfortable, and open avenue for communication. In order to provide the best care for our patients, 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. Verbal abuse will not be tolerated and may be grounds for dismissal from our practice.Signature of Owner or Responsible Agent*Date* MM slash DD slash YYYY How did you hear about our hospital? My Veterinarian Friend Internet Magazine Would you like to receive a copy of this form? No Yes
