Step 1 of 2 50% InstagramThis field is for validation purposes and should be left unchanged.Pet Owner InformationHas your pet previously been a patient of one of our Specialists before?(Required) Yes No Name of Owner(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone(Required)Primary Phone Type(Required) Cell Home Other Secondary PhoneSecondary Phone Type Cell Home Other Name of Co-Owner First Last Primary PhonePrimary Phone Type Cell Home Other Secondary PhoneSecondary Phone Type Cell Home Other Email Patient InformationPatient's Name(Required)Species(Required) Canine Feline Other Breed(Required)Color(Required)Age/DOB(Required)Sex(Required) Male Female Neutered Male Spayed Female Diet or brand fed(Required)How often fed(Required)When last fed(Required)Referring/Primary InformationPrimary ClinicClinic NameDoctorSend Records When Final? (Y/N)Referring ClinicClinic NameDoctorSend Records When Final? (Y/N)Additional Hospitals/ClinicsClinic NameDoctorSend Records When Final? (Y/N)Medical InformationAre your pet’s vaccinations up to date?(Required) Yes No Year of last rabies vaccine(Required)Please describe the current problem for which your pet is here(Required)List medications being administered (including over-the-counter medications). Please include dosage, frequency, and duration that the medication has been administered to your pet(Required)MedicationDosageFrequencyDuration Add RemoveHas your pet had any allergies or drug sensitivities?(Required) Yes No If yes, please list medications and reactionMedicationReaction Add RemoveHas your pet ever had a previous surgery?(Required) Yes No If yes, please describe briefly(Required)We love patient stories!Do we have your permission to share your pet’s image and story on our social media and/or website? Your name and personal information will never be shared, we only use your pet’s first name.(Required) Yes No We would love to hear!How did you hear about our hospital?(Required) My Veterinarian Friend Internet Magazine Other If other, please describe(Required)Signature of Owner or Responsible Agent(Required)Date(Required) MM slash DD slash YYYY Patient Care Practice PoliciesOne of the most important criteria for the delivery of veterinary medical care from veterinarians and staff members at Salt River Veterinary Specialists is an understanding of our patient care practice principals. Please be aware of the following practice policies as a client of Salt River Veterinary Specialists to navigate your pet’s care in collaboration with us: Patient health outcomes are impacted by adherence to the care plan prescribed by our doctors. Compliance with medications, diet, monitoring lab work, and recommended follow-up appointments is an essential part of your pet’s care. It is imperative that there is mutual trust and respect between doctors, staff, and clients. Please maintain a respectful demeanor when communicating your needs and concerns to our staff. Disrespectful and inappropriate temperament will not be tolerated and will be grounds for dismissal from our practice. Our doctors dedicate their daily schedules to in-office appointments. Therefore, they may be unable to answer or return phone calls the same day. Our support staff works diligently with our doctors to address patient concerns as swiftly as possible but please understand same-day answers may not be possible due to emergent patients. Our doctors are unable to review follow-up lab work performed by an outside veterinarian after your initial consultation. We value the expertise of our colleagues and defer to their recommendations if they have ordered lab work for your pet. Recheck appointments are available for additional follow-up questions or concerns regarding lab work performed by an outside veterinarian. Please notify our hospital at least 24 hours in advance of your scheduled appointment should you need to cancel your visit. If an appointment is cancelled without notice, a non-refundable deposit of the exam fee will be required before scheduling future appointments. Salt River Veterinary Specialists is a specialty referral hospital, not an emergency clinic. We are not always able to arrange same-day urgent appointments once we reach capacity. Our doctor may need to refer your pet to an emergency clinic for urgent or emergency care when providing updates by phone regarding your pet’s status. Payment in full is due at the time services are rendered. Should your pet need hospitalization, a prepayment will be required (payments may be made by cash, Visa, Mastercard, American Express, Discover, CareCredit, or Scratchpay). By signing below, you acknowledge you will adhere to Salt River Veterinary Specialists’ Patient Care Practice Policies. Signature of Owner or Responsible Agent(Required)Date(Required) MM slash DD slash YYYY
