Veterinary Health Record in American Fork, UT

INDIVIDUAL VETERINARY HEALTH RECORD

OWNER’S NAME(Required)

First Last

SPOUSE:

ACCOUNT No.

LIST ALL PEOPLE LEGALLY AND FINANCIALLY RESPONSIBLE FOR THIS ANIMAL, NOT LISTED ABOVE(Required)

MAILING ADDRESS(Required)

Street Address City State / Province / Region ZIP / Postal Code

PRIMARY MOBILE PHONE(Required)

SECONDARY PHONE

WORK PHONE

ACTIVE E-MAIL ADDRESS(Required)

PLEASE MARK ALL WAYS YOU’VE HEARD ABOUT US OR SEEN OUR ADS(Required)

GOOGLE

FACEBOOK

OUR WEBSITE

YOUTUBE

GROCERY CART

OFFICE SIGN

YELP

STREET SIGN/BANNER

KSL

RADIO

YAHOO!

BING

DEX

FRIEND/RELATIVE

Other

Other:

PATIENT’S NAME(Required)

SPECIES(Required)

PRIMARY BREED(Required)

COLOR / PATTERN(Required)

AGE / D.O.B.(Required)

MICROCHIP(Required)

GENDER(Required)

Male

Neutered

Female

Spayed

PATIENT ID:

(Required)

DEWORM H.W.PREV

BORDETELLA FeLV

DA2PP FVRCP

RABIES

WEIGHT

AGE

OWNER/CLIENT’S RESPONSIBILITY AND AGREEMENT

OWNER’S CONSENT FOR PATIENT TREATMENT(S):

I(Required)

am the legal owner/agent of said animal patient, and have authority to consent to all treatments. I, the undersigned owner of admitted animal patient, hereby request and authorize Dr. Rivera and/or such associates and assistants as may participate with him, or any other doctor(s)/veterinarian(s), to perform and administer all medical and surgical treatments as needed, and such additional procedures as are considered therapeutically and/or diagnostically necessary on the basis of findings during the course of treatment. I consent to the administration of such medications and anesthetics as are necessary.

TREATMENT, DICLOSURE, SURGERY AND ANESTHESIA RELEASE:

I(Required)

understand that in the performance of any surgical and/or anesthetic procedures there are risks such as, but not limited to, loss of blood, infection, cardiac arrest, and risks knows and unknown. I am aware that the practice of medicine and surgery is not an exact science and acknowledge that no guarantee or assurance has been made to me concerning the results of said medical and/or surgical procedure. I recognize that it is my responsibility to disclose to my veterinarian any physical condition and medication recently given which may be detrimental in any way to the success of said procedure or treatment. Doctors and staff are to use all reasonable precaution against injury, escape, or death of my pet. I understand that all anesthesia procedures involve some risk to my pet and I will not hold the doctor(s), his staff, or the hospital responsible under any circumstances. I understand and assume all risks. I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment, and release them of any and all liability

CLIENT’S RESPONSIBILITY FOR PET AND LIABILITY RELEASE:

I(Required)

accept all liability, fault and responsibility for my property, my pet and his or her actions, including, but not limited to any dog bites to anyone, including myself, while at Utah Veterinary Hospital and associated locations, and accept all liability for any injury, damage, harm and hazard my pet may present and cause to myself, Dr. Rivera and his staff, other parties and individuals, and any property. Further, I enter the hospital premises at my own risk, understanding fully there are inherent hazards, dangers and risks present in a veterinary hospital and associated locations. I understand and assume all risks, and I will not hold Dr.Rivera, his staff, or the hospital responsible, liable or at fault, or any related parties, in whole or in part, under any circumstances, ever. Moreover, I agree not to criticize, judge, defame and/or speak ill, in any form, of this business and/or any of its owners, employees and/or agents, in any private or public medium, in any form, facet, aspect, and/or review, in whole or in part, and I fully agree to immediately remove any such criticism, judgment, defamation, or any actions of its likeness, upon request from this business, or this business’s legal counsel, to do so. I also agree to keep information from these visits completely confidential, and not divulge it in any degree, anywhere.

CLIENT’S RESPONSIBILITY FOR COSTS, CHARGES AND BILLS, and PERMISSIONS:

I(Required)

assume all financial responsibility for all charges incurred by the patient’s care during the course of treatment and/or hospital stay, consent to the release of medical information, and authorize direct payment to Dr. Samuel Rivera and/or Utah Veterinary Hospital. Also, I agree to pay in full, the appropriate currency, upon discharge of my pet, and agree to a $20.00 (twenty-dollar) fee per month as service charge for unpaid balances. Further, I understand and agree that all delinquent accounts will be charged an interest rate of 1.5% per month (18% per annum). In the event any balance is not paid as agreed, I agree to pay an additional collection fee, not exceeding 40% of the unpaid balance In the event a lawsuit is brought against me to collect the unpaid balance, I further agree to pay my debtor’s court costs and reasonable attorney fees in addition to the collection fee. I further authorize Utah Veterinary Hospital or their agent(s) to call me at any number I provide or at any number, which is deemed necessary to contact me, including calls to mobile, cellular, or similar devices for any lawful purpose. I, the undersigned, also agree to any fee(s) or charge(s) that may be incurred for incoming calls from Utah Veterinary Hospital or their agent(s), and/or outgoing calls to them, to or from any such number, without reimbursement. Moreover, I grant them full permission to use any pictures and/or videos taken of my pet(s) and its treatments, and relinquish any potential proprietary or copy right to said media, and permit Utah Veterinary Hospital to use said media for any educational, promotional, and/or any other lawful uses. I consent to the disclosure of my animal’s care in accordance with Utah Code 58-28-605(1)(a).

RETURNED CHECK POLICY AGREEMENT (UTAH VETERINARY HOSPITAL DOES NOT ACCEPT CHECKS), NO REFUND POLICY:

I(Required)

understand and agree that if I decide, and if permitted, to make a payment with any check, and if any portion of the check is returned unpaid, Utah Veterinary Hospital and/or their agent(s) may then debit my checking account for the amount of the check, plus a service charge in the maximum amount allowed by law, and payment by check constitutes acceptance of these terms. I agree and understand that Utah Veterinary Hospital does not accept payment by check, does not provide or allow refunds for any goods or any services rendered, and does not accept returns, without exception. Additionally, I agree to pay any and all reasonable attorney and legal fees incurred by Dr. Rivera, and/or Utah Veterinary Hospital, in their efforts to collect or cure any check defect, or balance, and/or if any legal action is taken against me, or anyone involved with me, or this account, for any reason, until all legal disputes are settled.

Initials(Required)

Owner(s)/Clients’ Name(s) (print)(Required)

Owner(s)/Clients’ Signature(s) (sign)(Required)

Date(Required)

MM slash DD slash YYYY