“Experience the Compassionate Difference”
CLIENT REGISTRATION FORM
___________________________________________________CLIENT INFORMATION__________________________________________________
NAME: ______________________________________________
SPOUSE/PARTNER: ____________________________________________
STREET: _____________________________________________
CITY: ___________ STATE: ____ ZIP: _________ COUNTY: ___________
PRIMARY NUMBER: (____) ___________ [ ] HM [ ] WK [ ] CELL
SPOUSE/PARTNER NUMBER: (____) ___________ [ ] HM [ ] WK [ ] CELL
SECONDARY NUMBER: (____) __________ [ ] HM [ ] WK [ ] CELL
EMERGENCY CONTACT: _________________________________________
ADD’L AUTH. PERSONS TO BRING IN PETS: ________________________________
PREFERRED CONTACT METHOD: [ ] EMAIL [ ] PHONE [ ] TEXT
EMPLOYER/POSITION: ________________________________________________
EMPLOYER TELEPHONE NUMBER: (___) _______________
ARE YOU OVER THE AGE OF 65 OR MILITARY? ___________
EMAIL: ________________________________________________
(WE DO NOT SELL YOUR EMAIL ADDRESS; IT IS USED FOR HOSPITAL COMMUNICATION)
REFERRED BY: _____________________________________________
(WE HAVE A REFERRAL PROGRAM AND LIKE TO THANK OUR CLIENTS!)
____________________________________________ INFORMATION AND LIABILITY RELEASE___________________________________________
Tuscawilla Oaks Animal Hospital (GatorVets PA) advises that all fees are due in full upon discharge of your pet. If your pet is hospitalized, 50% of the
estimated amount is due as a deposit with the balance to be paid upon discharge and you may be asked to make payments towards your account
as fees accrue with treatment. We accept cash, check (no temporary or business), and most credit cards along with third party funding, such as
CareCredit (w/minimum of $200), pet insurance, etc. Please be aware that checks can be processed electronically and funds are withdrawn
immediately; if any check is returned we charge $25. A fee of $21 is charged for clients who miss or cancel more than 3 appointments in a calendar
year without 4 hours’ notice. We reserve the right to refuse service to anyone and the acceptance of checks without prior notice.
You certify that you are over 18 years of age and the owner or owner’s authorized agent of any pet that is listed in your file. You assume full
responsibility for all fees. You agree that should your account become delinquent you will be responsible for all collection costs, including but not
limited to the outstanding balance, attorney fees, court costs, collection agency fees and interest at the rate of 18% per annum (1.5% per month)
Initial: _____
Tuscawilla Oaks Animal Hospital may take photographs/videos of your pet and use its medical information for teaching, veterinary literature and
publishing. You authorize the release of your pet’s photographs and medical information for such purposes. Client privacy and medical
confidentiality will be maintained. Initial: _____
You understand that veterinary medicine is not an exact science and animals respond individually and unpredictably to hospitalization, treatment
and surgery. We make no guarantee as to any particular outcome of your pet’s case. You agree to release Tuscawilla Oaks Animal Hospital and its
staff from all liability associated with hospitalization, treatment and surgery performed on your pet.
Initial: _____
Please be aware that any and all pets that come into the hospital that have fleas may be given a deflea bath and/or Capstar on admission, which
will be at the owner’s expense.
Tuscawilla Oaks Animal Hospital is not a 24 hour facility and staff is not present during overnight hours when the hospital is closed.
Many of the drugs veterinarians prescribe for the treatment of their patients are not approved by the FDA (Federal Drug Association) for all or any
animal species and their use is considered “off-label.” However it is a legal and well accepted practice for veterinarians to prescribe and use these
drugs in this manner. We may use drugs “off-label” to treat your pet and you give your consent by accepting treatment for your pet at this facility.
By law we are required to maintain accurate client and patient information and verify information on a regular basis. This form needs to be fully
completed and you will periodically be required to update this form.
_______________________________________
NAME OF OWNER OR AUTHORIZED AGENT
_________________________________________
SIGNATURE OF OWNER OR AUTHORIZED AGENT
______________________
DATE