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Client/Patient Information Form
Thank you for choosing
Less Stress for Your Pet At Home Veterinary Medical Services
. Please take a moment to familiarize me with you and your pet companion. If you prefer, you may also
download a version of this form
, which can be completed using Microsoft Word and then e-mail or fax me the completed form.
Please make sure to call my office 860-342-4519 after filling out form.
Your Information (human)
*
Indicates required field
Date
*
How did you hear about this service?
*
Client Name
*
First
Last
Email
*
Street Address
*
Line 1
Line 2
City
State
Zip Code
Country
Mailing Address (if different from street address)
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number (Home)
*
Phone Number (Work)
*
Phone Number (Cell)
*
Patient One Information (pet)
Please note all fields are required in order to submit this form. If you are not sure of the answer, please do the best you can to answer the question. Additional comments can be included in the last field of this form.
Patient One Name
*
Species
*
Dog
Cat
Breed
*
Color
*
Sex
*
Male
Female
Spayed/Neutered
*
Yes
No
Date of Birth
*
Does your companion have any medical conditions?
*
Is your companion currently on any medications? Please list.
*
Patient Two Information (pet)
Please note: complete all fields if you have a second pet to register.
Patient Two Name
*
Species
*
Dog
Cat
Breed
*
Color
*
Sex
*
Male
Female
Spayed/Neutered
*
Yes
No
Date of Birth
*
Does your companion have any medical conditions?
*
Is your companion currently on any medications? Please list.
*
Consent for Treatment
I am at least 18 years of age. I authorize and direct
Dr. Eric Hurwit
of
Less Stress For Your Pet At Home Veterinary Medical Services
, LLC
and any designated assistant(s), to administer treatment as needed in his/their professional judgment on the basis of the findings during the course of evaluation, including without limitation, prescribing medication, testing and other diagnostic procedures, as may be advisable for the animal's well-being. I understand that I will be advised as to the nature of the treatment being performed and that I have been advised of and am fully informed of the risks involved and I am responsible for the decisions taken. I understand that no warranty or guarantee is made as to the results or cure. An estimate of these fees will be provided at my request for the initial assessment and treatment for the animal presented. I realize that actual fees may differ from the estimate dependent on the animal’s condition. I will be responsible for monitoring the ongoing fees and will be fully responsible for all fees incurred through the animal’s diagnosis and treatment at the conclusion of the visit.
Please check this box indicating your consent.
*
I have read and understood this consent.
Submit
Home
Clients
Veterinary Emergency and Referral List
Services and Information
Online Client/Patient Information Form
Client Home Supply List
Euthanasia
Downloadable Forms and Information
Make a Payment
Pet Care Articles
Helpful Sites
About the Doctor
Contact