Utah Veterinary Hospital

(801) 692-1563

161 East 30 N, American Fork, UT 84003

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Veterinary Health Record

INDIVIDUAL VETERINARY HEALTH RECORD

OWNER’S NAME(Required)
MAILING ADDRESS(Required)
PLEASE MARK ALL WAYS YOU’VE HEARD ABOUT US OR SEEN OUR ADS(Required)
GENDER(Required)
(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):

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:

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:

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:

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:

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.
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Testimonials

I brought in my 9 week old kitten who had an injured leg. They were so compassionate and took the best care of him. He is in a splint and will do... read more

Melissa D.

UVH is awesome! I take my puppy Kona here and the whole staff is wonderful and welcoming and take care of Kona with care! I'm glad I chose this... read more

TaNaya H.

Absolutely amazing! I would recommend them to everyone! Not one animal hospital in salt lake would see my guinea pig, the drive was a little far but... read more

Anastasia A.

Melissa D.

I brought in my 9 week old kitten who had an injured leg. They were so compassionate and took the best care of him. He is in a splint and will do laser therapy to heal quicker. I am so grateful they had a cancellation and could get me in. Dakota and Dr Rivera explained everything to me with upfront pricing that I could afford. I will be bringing both of my kittens here for all their veterinary needs. Again I am so grateful, a day later and my kitten is comfortable and healing.

TaNaya H.

UVH is awesome! I take my puppy Kona here and the whole staff is wonderful and welcoming and take care of Kona with care! I'm glad I chose this veterinary hospital!

Anastasia A.

Absolutely amazing! I would recommend them to everyone! Not one animal hospital in salt lake would see my guinea pig, the drive was a little far but well worth it!! Great staff and doctors. Very clean and so welcoming!!!

Utah Veterinary Hospital

161 East 30 N
American Fork, UT 84003

(801) 692-1563

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  • About Our Office in American Fork, UT
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  • Home
  • Hospital Tour
  • Meet Our Team
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    • Veterinary Health Record
  • Office Policies
  • Our Veterinary Services in American Fork, UT
    • Animal Radiography X Rays in American Fork, UT
    • Dental Care in American Fork, UT
    • Dog & Cat Examinations in American Fork, UT
      • Cat Diagnostic Tests Lab Tests in American Fork, UT
      • Cat Parasite Control in American Fork, UT
      • Cat Vaccinations Shots in American Fork, UT
      • Deworming Cats And Dogs in American Fork, UT
      • Digital Ultrasound in American Fork, UT
      • Dog And Cat Surgeries in American Fork, UT
      • Dog Diagnostic Tests Lab Tests in American Fork, UT
      • Dog Parasite Control in American Fork, UT
      • Dog Vaccinations Shots in American Fork, UT
    • Dog Cat Urgent Veterinary Care in American Fork, UT
    • Emergency Pet Care in American Fork, UT
    • Euthanasia in American Fork, UT
    • Exotic Pet Examinations in American Fork, UT
    • Laser Therapy in American Fork, UT
    • Pet Dehydration and Heatstroke in American Fork, UT
    • Pet Orthopedics in American Fork, UT
    • Pet Surgery in American Fork, UT
    • Spaying and Neutering in Utah
      • Canine Spay And Neuter in American Fork, UT
      • Feline Spay And Neuter in American Fork, UT
    • Veterinary Dermatology in American Fork, UT
    • Video Scope Ears Nose Throat in American Fork, UT
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