AVS TEST PAGE

For your convenience, PLEASE find our patient history form. We will receive a copy of your information, but Please also bring a copy of all completed paperwork to your appointment.

New Patient Registration
414 E. Carrillo Street, Santa Barbara, CA 93101

PH (805) 729-4460 FAX (805) 965-8387
Name *

First Name Primary Guardian’s Last Name
Name

First Name Secondary Guardian’s Last Name
Relationship to Primary Guardian
Phone Numbers – Please circle which to contact first
Cell:
Home:
Cell:
Home:
Mailing Address
Street Apt/Lot
Guardian’s Date of Birth

Month Day Year
Date
Guardian’s Date of Birth

Month Day Year
Date
Driver’s License
Driver’s License
Address

Email Address

Street Address Line 2

Zip Code
Email Address
example@example.com
Occupation
Preferred Pharmacy, City
How did you learn about our hospital? (Circle one)
Other (please specify):
Who may we thank for your referral?
Pet’s Name
Dog/Cat/Other
Breed
Sex
Spay/Neuter
DOB/Age
Color
Has your pet ever bitten anyone? *
Is your pet taking medications or on a special diet? *
Primary Veterinary Clinic *
Primary Veterinarian *
Is this where you would like records sent to?
Up to Date on Vaccines?
Up to Date on Vaccines?
Authorization to Provide Care
I confirm I am 18 years old (or older) and I am the guardian (or authorized agent of the guardian) for the pet(s) listed above. With my signature, I authorize the veterinarians and staff of Advanced Veterinary Specialists to examine, treat, administer medications, and perform diagnostic, surgical procedures, and/or to hospitalize my pet if the doctor(s) deem it necessary for the health, safety or well-being of my pet. I understand that except in dire emergencies all treatments and procedures will be discussed with me prior to implementations. I agree to assume responsibility for all charges incurred in the care of my pet(s), as well as reasonable attorney's fees, court costs, and interest if the balance is sent for collection. I

understand that full payment is due at the time services are rendered, and that Advanced Veterinary Specialists does not bill for services or

provide payment plans for treatment. Payments must be made with cash, Visa, MasterCard, Discover, American Express, Care Credit or a Check pre-printed with your name and address. At least one picture identification (driver's license, etc.) is required if you pay by check or credit card.

I acknowledge that I have read, understand and agree with the above information.
Signature:

Clear
Date:

Month Day Year
Date
Please bring all medications and any medical records you have for your pet(s) to their first visit.
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

AVS TEST PAGE

For your convenience, PLEASE find our patient history form. We will receive a copy of your information, but Please also bring a copy of all completed paperwork to your appointment.

New Patient Registration

Mailing Address

Authorization to Provide Care