New Client Form

Southwest Veterinary Surgical Service, PC

New Client Information

We understand that coming to a specialty practice can be overwhelming for both you and your pet. Although if you are here, chances are your pet may need board certified surgical care. If that is the case, we truly thank you and your veterinarian for choosing Southwest Veterinary Surgical Service. While with us, your pet is our pet, and we will do everything in our power to provide the best possible outcome.

For an easy and smooth process, please begin by filling out this new client form prior to your pets appointment so we can become better acquainted. If you need any assistance through this process, please do not hesitate to reach out. We welcome the opportunity to guide you through your experience with us.

Please select the location of your appointment *

Gilbert
Peoria
Scottsdale
Tucson

Scheduled Appointment Date *

Scheduled Appointment Time *

If your pet requires immediate scheduling for a non life- threatening procedure, please contact one of our offices directly for your pets prompt and appropriate scheduling needs.
Gilbert: 480-635-1110 ext 3
Peoria: 623-298-5354
Scottsdale: 480-339-2200 ext 6
Tucson: 520-301-2387

If other, please specify:

Owner Full Name *

First

Last

Owner's Primary Phone Number *

Co-Owner Full Name

First

Last

Co-Owner's Primary Phone Number

Address *

City *

State *

Zip Code *

Primary Email *

Secondary Email

Other Account Contact (may obtain medical information) - Pet Sitter Name

First

Last

Pet Sitter Phone Number

Friend Name

First

Last

Friend Phone Number

Family Member Name

First

Last

Family Phone Number

Primary Care Veterinarian - Doctors Name *

Primary Care Veterinarian - Clinic Name *

Referring Veterinarian Name (If different from Primary Doctors Name)

Referring Clinic Name (If different from Primary Clinic Name)

Pet Information - Patient Name *

Species *

Breed *

Color *

Sex *

Spayed/Neutered? *

Age/Birthday *

Reason for Visit *

Duration of Problem *

Current Medications/Dosages

Known Drug Allergies

Other Major Medical Issues

Is your pet's rabies vaccine current? *

Yes
No
Other

Other should only be used in the case that the animal has been rescued or found, etc.

If other, please specify the situation:

CONSENTS: I authorize and direct the veterinarians at Southwest Veterinary Surgical Service to examine, diagnose, prescribe, perform therapeutic procedures, and/or surgery that their judgment may dictate to be advisable for the patient’s well being. No warranty or guarantee has been made as to the result or cure. ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF THE VISIT. We accept cash, all major credit cards, Synchrony CareCredit, and checks with the required identification. There will be a service charge for any returned checks. A deposit is required at the time of admission and the balance paid in full at discharge. If you have any questions about the fees or the financial policy, please alert a staff member before services are performed. Accounts not paid within 30 days are subject to an interest finance charge. In the event any balance due is not paid as agreed, the undersigned jointly and severally agrees to pay all cost included in the unpaid balance, including a reasonable collection and /or attorneys’ fees. *

I have read and understand the financial policy

I hereby authorize Southwest Veterinary Surgical Service, PC and those acting in pursuant to its authority to: (a) Record to my pets’ likeness on video, audio, photographic, digital, electronic or any other medium. (b) Use my pets’ first name in connection with these recordings. (c) Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM, Internet/WWW) these recordings for any purpose that Southwest Veterinary Surgical Service, and those acting to its authority, deem appropriate, including promotional or advertising efforts. *

I have read, fully understand the terms of this release, and hereby certify that I am the parent/guardian/owner of the patient listed above. I do give my consent without reservations to the foregoing on behalf of him/her/them. I understand that all such recordings, in whatever medium, shall remain the property of Southwest Veterinary Surgical Service.
I decline and do not consent to the use of any images or information of my pet, taken by Southwest Veterinary Surgical Service, in any and all marketing or teaching materials.

When drugs are FDA-approved for use in one species but are administered to species other than those for which they have been approved and labeled, the terminology is that the drugs are being used in an “extra-label” manner. Extra-label use does NOT include the use of experimental drugs or drugs manufactured in foreign countries that have not been approved by the FDA. Because few drugs are labeled for use in small animals, most drugs administered by small animal or exotic animal veterinarians, including antibiotics, anesthetic agents, and other medications, are routinely used in an extra-label manner. This is within the standard of care, but good medical practice requires that owners be advised when drugs are being used in an extra-label manner. *

I authorize the staff at this veterinary practice to administer and prescribe extra-label drugs for my pet. I understand that any drug, including those that are used in an extra-label manner, can produce undesirable side effects. Thus, I acknowledge that it is my responsibility to administer prescribed medications for my pet as directed and to notify my veterinarian of any apparent side effects or complications.

Signature of Responsible Party *

First

Last

Must be over 18 years of age

Today's Date *

Comment

Feel free to print out this new patient information handout. Here you can read how to prepare for your pets consult or surgical procedure, what to expect during your visit, and general surgical discharge information.

New Patient Information

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Southwest Veterinary Surgical Service, PC

New Client Information

GILBERT

PEORIA

SCOTTSDALE

TUCSON