Healthcare Veterinary Renewal Form

HEALTHCARE VETERINARY RENEWAL FORM

Clinic and Administrative Information

Clinic Name:

Client ID / Account Number:

Owner / Responsible Party

Primary Phone:     Secondary Phone:

Patient (Animal) Information

Patient Name:     Species:

Breed:     Color / Markings:

Date of Birth:     Age:     Weight:

Sex: Male Female Neutered Spayed

Microchip Number:

Insurance & Billing

Medical History (Update)

Date of last vaccinations / preventative care:

Vaccinations & Preventive Care Renewal

I authorize renewal and administration of routine vaccinations and preventive treatments as recommended by the attending veterinarian: Authorize Decline

Select requested vaccinations / preventives for renewal (check all that apply):

Rabies DHPP / DAPP Bordetella Leptospirosis FVRCP Heartworm Preventive Flea / Tick Preventive

Authorization for Treatment and Release

By signing below, I certify that I am the owner or authorized agent for the patient named above. I authorize the veterinarians and staff of the clinic to perform diagnostic procedures, administer medications and vaccines, and provide routine medical and surgical treatment as deemed necessary. I acknowledge that veterinary medicine is not an exact science and that no guarantees have been made regarding outcomes.

I understand the risks and benefits associated with recommended procedures, including but not limited to allergic reactions, adverse drug reactions, anesthetic risk, and complications inherent to surgery. I have had an opportunity to discuss recommended care and ask questions.

Emergency authorization if I cannot be reached: Authorize emergency treatment up to $ without additional authorization Decline emergency treatment without contact

Euthanasia will not be performed without express, separate consent, except in circumstances where it is necessary to prevent undue pain and suffering and immediate consent cannot reasonably be obtained.

Financial Responsibility & Insurance Acknowledgment

I agree to be responsible for all charges incurred in the care of the patient. Insurance is considered a secondary payer; I remain ultimately responsible for payment of all fees. Estimates provided are not guarantees and additional charges may be incurred if treatment plans change.

Payment method on file may be used to settle balances for which I am responsible: Authorize use of card on file

Release of Records & Privacy

I authorize release of medical records and vaccination certificates to insurers, referring veterinarians, or designated persons as necessary for continuity of care or insurance claims. I understand veterinary medical records are maintained by the clinic and may be released as required by law.

Authorization expiration date:

Acknowledgment and Certification

I certify that the information provided on this renewal form is true and complete to the best of my knowledge. I understand failure to disclose relevant medical history may affect the safety and efficacy of treatment. I agree to notify the clinic promptly of any changes to the information on this form.

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