Client Registration

Date:

OWNER Last Name:

First Name:

Address:

APT:

City:

Zip:

Owner’s Primary Phone #

Email:

Spouse/Co-Owner

Phone #:

Were you referred to our office by a veterinarian or their answering service / office? Yes No

If yes: Veterinarian/Clinic that referred you to us?

Who is your Primary Care Veterinarian?

Other veterinarians involved in your pets care

If you were not referred by a veterinarian, how did you hear about us? Internet friend drive by other

PET Name:

Species: (cat or dog)

Breed:

Color:

Date of Birth / Age:

Sex: Male Female

Spayed / Neutered Yes No

Up to date on Rabies vaccine?

Reason for Visit?

Do you currently have pet insurance? Yes No

If yes, please provide the name of your insurance provider and policy number (if applicable):

ㅤ By checking this box, you acknowledge that you understand your right to request a written prescription for your pet. By checking this box, you acknowledge that you understand your right to request a written prescription for your pet.

Emergency Examination Fee: $155.00

Full payment is required at the time services are rendered. A 75% deposit is required on all cases and emergency procedures where hospitalization is required. The balance will be due at pick up.

We will prepare a written estimate for services. We do not carry open accounts and hope the above alternatives are convenient for you. I agree to pay any costs and charges necessary for the collection of any amount not paid when due.

I am aware that LeadER Animal Specialty Hospital, in accordance with the American Veterinary Medical Association’s code of professional ethics, will provide only such emergency treatment as they deem necessary and that my pet and all it’s pertinent records will be sent back to the veterinarian that referred me as soon as practical. Under no circumstances will a client referred by another veterinarian be accepted as a regular client of LeadER Animal Specialty Hospital.

I give permission to use my Pet(s) images for educational purposes. Initial your choice: Yes No

Signature of Owner or Authorized Agent

CPR CHOICE

DATE:

OWNER NAME:

PET NAME:

I AUTHORIZE THE VETERINARIAN(S) OF LEADER ANIMAL SPECIALTY HOSPITAL TO EXAMINE AND PROVIDE EMERGENCY STABILIZATION OF (Pet)

AND I AM THE RIGHTFUL OWNER OR AGENT OF (PET)

I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL PROFESSIONAL FEES INCLUDING THE EXAM OF $155.00 AND IF NEEDED, INITIAL STABILIZATION WHICH CAN AND MAY INCLUDE IV CATHETER, FLUIDS, A SMALL BLOOD PANEL, BLOOD PRESSURE, GLUCOMETER AND INJECTABLE MEDICATIONS UP TO AND INCLUDING AN ADDITIONAL COST OF $400.00.

I UNDERSTAND THAT I WILL RECEIVE A WRITTEN ESTIMATE AFTER THE PET IS EXAMINED/STABILIZED BUT IT IS ONLY AN ESTIMATE BASED ON OUR FINDINGS AT THE TIME OF EXAMINATION AND THE FINAL BILL MAY VARY FROM THE ESTIMATE.

I REALIZE THAT NO GUARANTEE OR ASSURANCE CAN OR HAS BEEN GIVEN AS TO THE RESULTS.

I AM AWARE THAT LEADER ANIMAL SPECIALTY HOSPITAL IN ACCORDANCE WITH THE AMERICAN VETERINARY MEDICAL ASSOCIATION'S CODE OF PROFESSIONAL ETHICS, WILL PROVIDE ONLY SUCH EMERGENCY TREATMENT AS THEY DEEM NECESSARY.

IF MY PET WAS REFERRED BY ANOTHER VETERINARIAN OR ANOTHER VETERINARIANS OFFICE, I UNDERSTAND THAT MY PET AND ALL PERTINENT RECORDS WILL BE SENT BACK TO THE REFERRING VETERINARIAN. UNDER NO CIRCUMSTANCES WILL A PET REFERRED BY ANOTHER VETERINARIAN BE ACCEPTED AS A REGULAR PATIENT OF LEADER ANIMAL SPECIALTY HOSPITAL.

In the event that CPR (cardiopulmonary resuscitation) is required for my pet, I authorize the following initialed choice: YES give my pet CPR No resuscitation efforts

OWNER OR AUTHORIZED AGENT SIGNATURE

OWNERS BEST PHONE NUMBER

DOCTOR / CLINIC THAT REFERRED YOU HERE TODAY

Reach Out To Us

24/7/365

9410 Stirling Rd, Cooper City, FL 33024

(954) 437-9630

Drive here

call us

19357 SR-7 Boca Raton, Fl 33498

(561) 934-5323

CPR CHOICE

Reach Out To Us

24/7/365

9410 Stirling Rd, Cooper City, FL 33024

Drive here

call us

19357 SR-7 Boca Raton, Fl 33498

Drive here

call us

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