Name *

First

Last

Primary Owner Phone *

Primary Owner Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Owner Information

Only complete if your pet has a secondary owner.

Secondary Owner Name

First

Last

Secondary Owner Phone

Secondary Owner Email

Referring Veterinarian Information

Complete all that apply.

Primary Vet Clinic

Veterinarian's Name

Specialty Hospital

Specialist's Name

Additional Clinics Recently Visited

Pet Information

Pet's Name *

Photo of Pet

Click or drag a file to this area to upload.

Pet's Date of Birth *

Make your best guess if you do not know the exact date.

Pet's Breed *

Pet's Gender *

Male
Female

How long have you owned your pet? *

Is your pet primarily indoor or outdoor? *

Indoor
Outdoor
Mixed

Do you have any other pets in the house? *

Yes
No

Other pets

Please describe the other pets in your household.

Pet's Spay/Neutering History

Is your pet spayed or neutered? *

Yes
No

If yes, at what age?

If no, When was last heat?

Pet's Medical History

What is the primary concern you would like to address at your pet's visit? *

Does your pet have other previous and/or ongoing medical problems or issues? *

Yes
No

Describe other previous and/or ongoing medical problems or issues.

Does your pet have any known allergies or adverse reactions to medications? *

Yes
No

Describe allergies or adverse reactions to medications.

What is your pet's current diet? How much are they eating each day? *

What are your pet's current medications/supplements?

Please list Medication/Supplement Name, Dose & Frequency, and how long.

What are the locations and sizes of any lumps and bumps?

Photos of any lumps and bumps

Click or drag a file to this area to upload.

What are your goals for your pet's consultation? *

Educations about my pet's cancer
Pain control and palliative care
Treatment options and prognosis
Unsure/Other

If "Unsure/Other" please describe below:

Media Consent (optional)

I consent to the use of photos of my pet in promotional materials or educational materials (ex: Facebook, website, CE presentations).

I agree
I disagree

Medical and Financial Consent

I consent to the provision of medical services for my animal at Veterinary Cancer & Surgery Specialists. The preliminary diagnostics and therapeutic plans will be discussed with me along with the attendant risks and costs. I understand that no guarantee is made as to result or cure. I agree to be available by phone at all times during the hospitalization of my pet for consultation with the veterinarian of my pet. I understand that the staff will keep me informed of and receive my consent for recommended additional diagnostics and therapeutics along with concomitant costs. In the event that I cannot be reached, I authorize the doctors and staff to perform any procedures necessary for the well-being of my pet. *

I agree

Financial Consent

I understand payment is due at time of service. I am financially able to meet any commitments made. In the event of a check returned due to insufficient funds or stop payment, a $25.00 fee will be added to my account. A service charge of 1.5% and a $5.00 billing charge is applied per month to all balances over 30 days old. Should it become necessary to bring collection proceedings against me, I agree to pay not only the past due balance, but also any reasonable and customary expenses incurred in the collection process, including but not limited to, collection agency fees, attorney fees as awarded by the court and court costs. I understand the doctor will prepare an estimate after examining my pet and further understand that the estimate is based upon the initial examination of my pet. The estimate may change as further diagnostic and therapeutic procedures dictate. The estimate range is intentionally broad to anticipate unforeseen changes in medical condition. I understand that this is an estimate and that final charges are based upon procedures performed. *

I agree

Financial Certification

I certify that the information given by me is correct and I have read and consent to the terms of the medical and financial agreements. I am the owner of the pet or I am authorized as the agent or representative of the pet to execute the above and accept it's terms on behalf of the owner of the pet or assume individually all financial responsibility by signing below. I certify that I am legally authorized to give medical and financial consent. *

I agree

Digital Signature

Name *

First

Last

Name of the signatory (pet owner or authorized agent or representative).

Date *

Email *

Email address for the signatory.

Phone *

Phone number for the signatory.

Signature *

Clear Signature

Signature the signatory.

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Secondary Owner Information

Referring Veterinarian Information

Pet Information

Pet's Spay/Neutering History

Pet's Medical History

Media Consent (optional)

Medical and Financial Consent

Financial Consent

Financial Certification

Digital Signature

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