Online Forms

ONLINE FORMS

New Patient Form

Save time at your first appointment! Complete your required new patient form online before your visit.

New Patient Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Client Information

Name *

First

Last

Secondary Name on Account

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Contact Phone Number *

Secondary Contact Phone Number

Place of Employment *

Email *

example@example.com

Regular Veterinarian *

If you do not have a regular veterinarian, type none.

Patient Information

Pet's Name *

Pet's Date of Birth or Approximate Age *

Color of Pet *

Species of Pet *

Breed of Pet *

Sex of Pet *

Male
Female
Male (Neutered)
Female (Spayed)

CONSENT / DECLINE DIRECTIVE FOR CPR

Should, based on the medical judgment of the attending veterinarian, my pet named require cardiopulmonary resuscitation (CPR), I request or decline that the veterinarian(s) at the UVC pursue such medical care as indicated below. I understand that despite the best efforts of the veterinarians and staff, CPR may not save my pet’s life. I also understand that even the most successful CPR that restores my pet’s life may not allow my pet to regain his/her normal mental and physical health and, thus, may leave him/her as an invalid.

CPR Directive *

REQUEST FOR CPR - Having requested such emergency procedures, I agree to be held financially responsible for resuscitation fees associated with CPR. Regardless of my pet’s survival, I agree to pay these fees in addition to the other fees already identified by the practice and agreed upon by me.
DECLINE CPR - DO NOT RESUSCITATE MY PET. I have read the above information and understand that no CPR will be performed on my pet.

Signature *

Clear Signature

Professional fees are to be paid at the time services are rendered. We do not carry open accounts and hope that these alternatives are convenient for you: cash, Mastercard, Visa, American Express, Discover, debit cards, CareCredit and scratchPay. We do not accept checks.

I have read this form and I am aware of the hospital's payment policy and I agree to be personally responsible for payment in full for all services at the time services are rendered.

Today's Date *

Message

Online Forms

ONLINE FORMS

New Patient Form

New Patient Form

Client Information

Patient Information

CONSENT / DECLINE DIRECTIVE FOR CPR

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Location

Contact Information

Hours