Home » New Client Form: Additional Pets

New Client Form: Additional Pets

Step 1 of 2

Owner/Caregiver's Name(Required)

First

Last

Pet's Name(Required)

Species(Required)

Canine (Dog)

Feline (Cat)

Gender(Required)

Breed(Required)

Color/Markings(Required)

Date of Birth or Approx. Age(Required)

Microchip Number

If known/applicable

List any medications your pet is currently taking (including heartworm/flea and tick prevention)

What food(s) do you feed your pet?

List any medical procedures your pet has had

Has your pet ever had a reaction to a vaccine? If so, which ones – please explain

List any allergies your pet has

List any current or previous medical conditions your pet has/has had

List any concerns you have about your pet's health

Please tell us any other information we may need to know about your pet (1).

Collection and Usage of Personal Information

We may employ different vendors, such as Scribenote (provided by Scribenote, Inc.) or other similar vendors (the “System Vendor”) to provide the Application used to record and transcribe conversations between our veterinary staff and customers, with both parties’ consent, while fulfilling our customers’ pet care needs.

We do not use or disclose any information outside of what is necessary to transcribe notes relating to providing pet care, perform quality control review related to the treatment, and assert or defend claims related to providing our services. The Hospital and its System Vendor will not sell, lease, trade or otherwise profit from your information.

Retention and Destruction of Your Information

The transcript and recordings of veterinary visits are housed on third-party cloud servers that are maintained and secured by the System Vendor, and accessible by the Hospital. The Hospital and its System Vendors treat your information as confidential and exercise reasonable care to protect it from disclosure to unauthorized third parties. Your information will be destroyed by the Hospital and its System Vendor when the initial purpose for collecting or obtaining it has been satisfied or within one (1) year after the records are no longer needed for the pet’s treatment, unless required to be maintained for longer in accordance with applicable law or as necessary to defend against claims or assert the Hospital’s rights.

Hospital Use Only

HOSPITAL REPRESENTATIVE

CLIENT ACCOUNT NUMBER