Client Registration
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Pet Transport Form
Existing Client - Newberry Animal Hospital Van
Pet Owner/Client's Name:
Address
Cell Phone
LOCATION: I am choosing this hospital for my pet's treatment:
39th Avenue/Holistic Location - 3909 NW 97th BLVD, GAINESVILLE, FL 32606
Main Street Gainesville Location - 1609 S. MAIN ST, GAINESVILLE, FL 32601
Newberry Florida Location - 280 SW 250TH ST, NEWBERRY, FL 32669
Springhill Location - 3740 NW 83RD ST, GAINESVILLE, FL 32606
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Pet Patient #1
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Pet Transport Form
Existing Client - Newberry Animal Hospital Van
Pet Patient #1's Name:
Pet #1: What is your pet being seen for today?
Pet #1: Has your pet been eating normally?
Yes
No
If no, please describe:
Pet #1 What brand/type and quantity of food do you feed your pet?
Pet #1 Feeding Frequency?
Once Daily in AM.
Once Daily in PM.
Twice Daily.
Three Times Daily.
Pet #1 Has your pet had any of the following symptoms?
Coughing
Sneezing
Vomiting
Diarrhea
Limping
Itchy Skin
NONE
Pet #1 For any symptoms checked above, when did they start, and how often?(Skip this question if you selected NONE)
Pet #1 Please list any medications that you pet is currently taking (name of medication, strength, and instructions.) :
Pet #1 Does this pet need any refills on current medications?
Yes
No
Pet #1 If yes, which medication(s)?
Pet #1 Would you like any of these other services performed?
Anal Gland Expressed: $29.00
Ear Cleaning: $23.10
Nail Trim: $22.00
Nail Trim with Dremel: $28.00
Pet#1 And/Or a Bath?
Bath Under 50 lbs: $40.00
Bath Over 50 lbs: $50.00
Medicated Bath: $45.00
Pet #1: Additional comments, if needed:
Pet #1 Finally, are there any treatments you would like quoted and completed during this visit?
Do you have another pet to add?
Yes
No
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Patient Information
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Pet Transport Form
Existing Client - Newberry Animal Hospital Van
Pet Patient #2 Name, if applicable.
Pet #2: What is your pet being seen for today?
Pet #2: Has your pet been eating normally?
Yes
No
Pet #2 If no, please describe:
Pet #2 What brand/type and quantity of food do you feed your pet?
Pet #2 Feeding Frequency?
Once Daily in AM.
Once Daily in PM.
Twice Daily.
Three Times Daily.
Pet #2 Has your pet had any of the following symptoms?
Coughing
Sneezing
Vomiting
Diarrhea
Limping
Itchy Skin
NONE
Pet #2 For any symptoms checked above, when did they start, and how often?(Skip this question if you selected NONE)
#2 Please list any medications that you pet is currently taking (name of medication, strength, and instructions.) :
Pet #2 Does this pet need any refills on current medications?
Yes
No
Pet #2 If yes, which medication(s)?
Pet #2 Would you like any of these other services performed?
Anal Gland Expressed: $29.00
Ear Cleaning: $22.00
Nail Trim: $21.00
Nail Trim with Dremel: $28.00
Pet#2 And/Or a Bath?
Bath Under 50 lbs: $40.00
Bath Over 50 lbs: $50.00
Medicated Bath: $45.00
Pet #2: Additional comments, if needed:
Pet #2 Finally, are there any treatments you would like quoted and completed during this visit?
If we take a photo of any of your pet(s) while under our care, do we have your permission to use them on our Facebook/social media?
Yes
No
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You are almost done!!
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Pet Transport Form
Existing Client - Newberry Animal Hospital Van
In the event of an emergency and we are unable to reach you, who else would you like us to contact?
Name of Emergency Contact #1:
Emergency Contact Phone #1:
Name of Emergency Contact #2:
Emergency Contact Phone #2:
I am authorized to execute this consent in my capacity as owner/agent of the owner of the Patient named above.I authorize and direct Newberry Animal Hospital, Newberry Animal Holistic & Wellness, and its agents and representatives (collectively, “NAH”), to transport the Patient in a NAH transportation vehicle to NAH’s veterinary hospital located at "Location" (treating hospital indicated above) for evaluation and treatment. At all times during the transportation and following arrival at the Location, I further authorize and direct NAH to provide the Patient with such care, medication, and treatments, including, without limitation, anesthesia, x-rays or other imaging, and surgical procedures, as are considered therapeutically and diagnostically necessary by NAH; provided, however, that NAH will, in accordance with my choices set forth below. I agree to be available by phone for the purpose of giving authorization/consent for care. Should I be unavailable NAH will only provide emergency care as deemed necessary for the health of my pet.Except in the case of NAH’ willful misconduct or gross negligence, I, in my capacity as or on behalf of the owner of the Patient as the owner’s duly authorized agent, hereby irrevocably waive and disclaim any and all responsibility and liability of NAH for any and all damages and injuries to, related to or arising from the Patient, or caused by any action or inaction of NAH in, the transportation of the Patient to the Location (and, if applicable, the transportation of the Patient back to its owner) and/or the provision of such care, medication, and treatments, including, without limitation, anesthesia, x-rays or other imaging, and surgical procedures, both during and following the Transportation to the Location.
I understand and agree that payment for such charges is due in full no-later than the time of the Patient’s discharge from the Location.
All animals must be free of external parasites (ex. ticks, fleas, etc.), or they will be treated at owner's expense. For the avoidance of all doubt, please check the following boxes regarding how you would like NAH to proceed:CHOOSE ONE OF THE FOLLOWING:
PLEASE CALL ME IF TREATMENT EXCEEDS $200
PLEASE PERFORM SERVICES NECESSARY
PLEASE CALL ME PRIOR TO INITIATION OF NON-EMERGENCY CARE, MEDICATION, OR TREATMENT.
PLEASE DO NOT EXCEED THE AMOUNT OF:
...in US Dollars
USD
Do you want to add any AUTHORIZED CONTACTS? (read below):
'IT TAKES A VILLAGE' section: Please list below the names and phone numbers for any 'authorized contacts' you would like to add to your account.
'Authorized contacts' are defined as non-owners who you give authorization to:
1. make decisions (both medical and financial) on your behalf that you WILL BE responsible for, and
2. drop off and pick up any of your pets from our hospitals, and
3. authorize services on your behalf.
(Should you wish to make changes to your 'authorized contacts', this must be made in writing to the specific hospital location.)
'AUTHORIZED CONTACT' NAME:
'AUTHORIZED CONTACT' Phone #:
Electronic signature:
Clear
Date
MM
/
DD
/
YYYY
I'm interested in this pet transport service:
As soon as possible, please call me.
I have a certain day in mind, which I will provide at the end of this form.
I want a quote only, in case I want to use this in the future.
On what date would you like to schedule this pet transport?
MM
/
DD
/
YYYY
SUBMIT FORM
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