Owner Information

Owner First Name *

Owner Last Name *

Spouse / Secondary Owner First Name *

Spouse / Secondary Owner Last Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

Date of Birth *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

No

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

No

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing VSEC Thousand Oaks to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT

I HEREBY AUTHORIZE THE DOCTOR ON DUTY (AND ASSISTANTS THE DOCTOR MAY DESIGNATE) TO ADMINISTER TREATMENT AS CONSIDERED THERAPEUTICALLY AND/OR DIAGNOSTICALLY NECESSARY ON THE BASIS OF FINDINGS DURING THE COURSE OF SAID EVALUATION. I ALSO CONSENT TO THE ADMINISTRATION OF SUCH ANESTHETICS AND SURGICAL PROCEDURES AS ARE NECESSARY. I HEREBY CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT, THE REASONS WHY THE SURGERY IS CONSIDERED NECESSARY, ITS ADVANTAGES AND POSSIBLE COMPLICATIONS IF ANY, AS WELL AS POSSIBLE ALTERNATIVE MODES OF TREATMENT WHICH ARE EXPLAINED TO ME BY THE DOCTOR. I ASSUME FINANCIAL RESPONSIBILITY FOR ALL CHARGES INCURRED TO THE PATIENT AND CONSENT TO THE RELEASE OF MEDICAL INFORMATION TO THE ABOVE NAME FAMILY VETERINARIAN. I UNDERSTAND THE CLINIC AND ITS PERSONNEL DOES NOT GIVE ANY GUARANTEE THAT THE RECOMMENDED TREATMENTS/PROCEDURES WILL CORRECT OR CURE THE CONDITION FOR WHICH MY PET WAS PRESENTED. I UNDERSTAND THAT IF MY CHECK OR CREDIT CARD IS RETURNED UNPAID FOR ANY REASON THAT I WILL BE SUBJECT TO ADDITIONAL CHARGES AND THAT IF A COLLECTION AGENCY/ATTORNEY MUST BE USED TO COLLECT THE BALANCE OF THE CHARGES RESULTING FROM CARE RECEIVED BY MY PET AT VETERINARY SPECIALTY AND EMERGENCY CENTER, I WILL BE RESPONSIBLE FOR PAYING ANY COLLECTION COST/FEES.

DISPUTE RESOLUTION

ANY DISPUTE, CLAIM OR CONTROVERSY ARISING OUT OF OR RELATING TO THIS AGREEMENT OR THE PROVISION OF SERVICES OR PRODUCTS OF ANY TYPE THROUGH VETERINARY SPECIALTY AND EMERGENCY CENTER OF THOUSAND OAKS, INC. OR THE BREACH, TERMINATION, ENFORCEMENT, INTERPRETATION OR VALIDITY THEREOF, INCLUDING THE DETERMINATION OF THE SCOPE OR APPLICABILITY OF THIS AGREEMENT TO ARBITRATE, SHALL BE DETERMINED BY ARBITRATION IN VENTURA COUNTY, CALIFORNIA, BEFORE A SINGLE ARBITRATOR WITH EXPERIENCE IN COMMERCIAL ARBITRATION. THE ARBITRATION SHALL BE ADMINISTERED BY JAMS PURSUANT TO ITS JAMS' STREAMLINED ARBITRATION RULES AND PROCEDURES. JUDGMENT ON THE AWARD MAY BE ENTERED IN ANY COURT HAVING JURISDICTION. THIS AGREED PROCEDURE SHALL NOT PRECLUDE PARTIES FROM SEEKING PROVISIONAL REMEDIES IN AID OF ARBITRATION FROM A COURT OF APPROPRIATE JURISDICTION. IN ANY ARBITRATION ARISING OUT OF OR RELATED TO THIS AGREEMENT, THE ARBITRATOR SHALL AWARD TO THE PREVAILING PARTY, THE COSTS AND ATTORNEYS' FEES REASONABLY INCURRED BY THE PREVAILING PARTY IN CONNECTION WITH THE ARBITRATION. THIS AGREEMENT AND THE RIGHTS OF THE PARTIES HEREUNDER SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF CALIFORNIA, EXCLUSIVE OF CONFLICT OR CHOICE OF LAW RULES.

Advanced Directive

In the unlikely event your pet should require heroic or invasive life-saving intervention (cardiopulmonary arrest and resuscitation), you will be contacted immediately. However, in order to give your pet the best possible outcome, please indicate which of the following you authorize VSEC to perform should we be unable to contact you. There is a fee if CPR is performed on a pet patient if he or she suffers from cardiac or respiratory arrest.

Select One *

Signature

Signature *

Spam Blocker

New Client Intake Form

Option 1

Complete Online

Option 2

Print & Complete

Option 3

Complete on Arrival