Client Form - Less Stress for Your Pet At Home Veterinary Medical Services

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