New Client Form for Telemedicine Clients – Scottsdale Veterinary Hospital

Client Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone
Cell Phone
Email
Children's Name
Employer
Name and Work Number - Spouse / Significant Other
Spouse Employer
Emergency Name*
Emergency Phone
Patient Information
Name*
Species
Breed
Sex
Neutered/Spayed?
Previous Veterinarian/Hospital
Vaccine Status
Previous Medical History (ie. Surgeries, diagnosed conditions, trauma, etc.)
Current Medications (including supplements and nutraceuticals)
Current Diet
Temperament
Other pets in household
Payment Policy
Hospital policy requires payment at the time services are rendered. If you are not familiar with the cost of veterinary services, feel free to ask for an estimate/treatment plan prior to any treatments. For hospitalization , extensive care, or diagnostics , a deposit of 70% will be required prior to treatment.

We offer the following payment options: Cash, Debit Card, Visa, or Mastercard. NO CHEQUES ACCEPTED .
If you have pet insurance, who is your provider?
Consent*
I have read and understand the information provided regarding telemedicine and understand the limitations in diagnosing and providing care for my pet. By replying to this email (and participating in the telemedicine consultation), I hereby give my informed consent for the use of telemedicine in the medical care of my pet.
Click here to read our Telemedicine policy

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Client Information