If you are a new client, please print out this document, complete it, and turn it in to the receptionist when you arrive for your appointment.

*********************************************************************************

Welcome to Arizona Exotic Animal Hospital

Please tell the receptionist immediately if you believe your pet is not stable enough to wait!

Client Information

Last Name: ___________________________________ First Name:___________________________

Others Authorized for Account: Please list who can make an appointment, authorize treatment, or make a payment.

Name __________________________________________ Relationship__________________

Name __________________________________________ Relationship _________________

Address: _________________________________________________________________________

Apt: ________ City/State:____________________ Zip: _________

Home Phone: (_____)___________________ Work: (______)___________Cell: (____)_________

Other Phone(s):___________________________________________________________________

Your Place of Employment:__________________________________________________________

Email Address:___________________________________________________________________

Student or Active Military Member? Yes____No____(please show ID to receptionist to receive 10% discount)

Driver’s License Number: ______________________State:_____

Date of Birth: _______________________  Arizona state law requires us to have our client’s date of birth to dispense certain types of medication such as pain-relievers, sedatives, and some others.

Please complete the following for the exotic pet(s) you would like to have in your records:

Patient’s Name	Species/Breed	Age Y/M	Major Colors	Sex M/F/U	Spayed/ Neutered? Y/N

Do you have another Veterinarian? If so, who?_____________________________________________ 

Do you want us to inform this veterinarian about today’s visit? Yes____ No____

How did you hear about us?   Friend: ___________________________  Pet Store:______________    

Veterinarian (If different from above): _____________    Google___  Dexonline___  Other Internet____   Other:______________

Hospital Disclosures

Please read and initial the following statements.  Our staff will be happy to explain any of these statements prior to your initialing.

·         Restraint of Patient: I understand that my pet may act differently than it does at home and there is a chance it may bite, scratch, or otherwise attempt to injure anyone, including myself, handling it. I understand that I should not handle my pet during any procedures and that if I do this waives liability of the hospital if I am injured directly or indirectly by the actions of my pet during said procedures.  Initials: ________

·         Payment Due at Time of Service: I understand that payment is due at time of service. I understand that the following forms of payment are accepted: Visa, Master Card, American Express, Discover, cash, and personal in-state checks with appropriate ID.  We also accept Care Credit. Initials:_________

·         Extra Label Use of Drugs: I understand that there are few medications specifically licensed for use in exotic pets. I authorize the extra label use of medications on my pets.  Initials: _________

·         Life-threatening Conditions / Resuscitation Orders: I understand that some medical conditions may be life-threatening and impact the examination of my pet. If a life-threatening emergency is detected while your pet is here, the staff of Arizona Exotic Animal Hospital will try to stabilize your pet unless you initial the “Do Not Resuscitate” below.

o        DO RESUSCITATE: Initials: ________

o        DO NOT RESUSCITATE: Initials: ________

·         No Overnight Staff: I understand that Arizona Exotic Animal Hospital is not a 24-hour hospital facility.  I understand that I can request for my pets to be transferred to an emergency veterinary hospital with 24-hour care if overnight hospitalization is required.  Initials: ________

·         Photo or Medical Case Release:  Arizona Exotic Animal Hospital may want to use pictures and/or information resulting from the veterinary care of my pet on their website, social media sites, or for other educational purposes. Only the pet’s name and medical condition will be used. Client name, address and other personal information will not be used. I understand that if at any time I choose to revoke permission for the use of my pet’s photo or information I must notify the hospital in writing.

o        I AGREE: Initials: ________

o        I DO NOT AGREE: Initials: ________

Thank you for choosing us to care for your exotic pets!

Signature of financially responsible party:                 

X______________________________________________   Date:______________