24-HR ER: 760-466-0600
Our Services
Anesthesia and Pain Management
Blood Bank
Cardiology
Veterinary Dentistry
Dermatology
Diagnostic Imaging
Emergency/Critical Care
Internal Medicine
Interventional Radiology
Neurology
Oncology
Ophthalmology
Social Work
Surgery
Urgent Care by Ethos Near Here
For Your Pet
Client Registration Form
Emergencies + Appointments
Get in Line
When Your Pet is a Patient
Client Portal
Pet Insurance
Payment Options
Online Store
Prescription Refill Form
Grief Resources & Pet Loss Support
Clinical Studies
For Veterinary Teams
Submit Referrals
Our Referral Process
At a Glance
Ethos Materials for Clinics
Outpatient Imaging
Clinical Studies
VetBloom CE
About Us
Our Hospital
Our Team
Veterinary Urgent Care by Ethos
Ethos Discovery
Contact Us
Blogs & Videos
Our Blogs
PAWEDcasts
Careers + Development
VSH – North County is Hiring
Positions Across Ethos
Job Fair Events
Benefits and Perks
Veterinary Training Programs
Our Services
Anesthesia and Pain Management
Blood Bank
Cardiology
Veterinary Dentistry
Dermatology
Diagnostic Imaging
Emergency/Critical Care
Internal Medicine
Interventional Radiology
Neurology
Oncology
Ophthalmology
Social Work
Surgery
Urgent Care by Ethos Near Here
For Your Pet
Client Registration Form
Emergencies + Appointments
Get in Line
When Your Pet is a Patient
Client Portal
Pet Insurance
Payment Options
Online Store
Prescription Refill Form
Grief Resources & Pet Loss Support
Clinical Studies
For Veterinary Teams
Submit Referrals
Our Referral Process
At a Glance
Ethos Materials for Clinics
Outpatient Imaging
Clinical Studies
VetBloom CE
About Us
Our Hospital
Our Team
Veterinary Urgent Care by Ethos
Ethos Discovery
Contact Us
Blogs & Videos
Our Blogs
PAWEDcasts
Careers + Development
VSH – North County is Hiring
Positions Across Ethos
Job Fair Events
Benefits and Perks
Veterinary Training Programs
24-HR ER: 760-466-0600
760-466-0600
Client Registration Form
Step
1
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4
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Owner Information
Title
*
Ms.
Mrs.
Mr.
Dr.
First Name
*
Last Name
*
Date of Birth
*
Month
Day
Year
State Guidelines require that the caregiver’s date of birth be recorded when distributing controlled medications.
Email Address
*
We will use your email to send appointment reminders, medical communications and a client survey.
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
*
Preferred Phone Number
*
Phone Type
*
Mobile
Home
Work
I grant permission to the hospital medical team to text reminders and updates to the mobile number provided here
*
Yes
No
Secondary Phone Number
Phone Type
Mobile
Home
Work
Co-owner/Alternate Contact
Co-owner Title
Ms.
Mrs.
Mr.
Dr.
Co-owner First Name
Co-owner Last Name
Co-owner Date of Birth
Month
Day
Year
State Guidelines require that the caregiver’s date of birth be recorded when distributing controlled medications.
Co-owner Email Address
We will use your email to send appointment reminders, medical communications and a client survey.
Co-owner Contact Number
Phone Type
Mobile
Home
Work
I grant permission to the hospital medical team to text reminders and updates to the mobile number provided here
Yes
No
Patient Information
We take pictures of your pet for identification and as part of the medical record. These photos are not shared outside of the medical record.
Name of Pet
*
Pet's Date of Birth
*
Month
Day
Year
Please approximate if you are unsure. We use this information on prescriptions.
Sex of Pet
*
Neutered Male
Intact Male
Spayed Female
Intact Female
Species
*
Canine
Feline
Breed
*
Color
*
Pet Insurance Carrier
None/Don't know
24PetWatch
AKC Pet Insurance
ASPCA Pet Insurance
Banfield Optimum Wellness Plan
Embrace
Fetch - (formerly Pet Plan)
Figo
Hartville Pet Insurance
Healthy Paws
Lemonade
Nationwide Pet Insurance (VPI)
Pet Assure
Petco Pet Insurance
PetFirst (MetLife)
Pets Best
Prudent Pet
Pumpkin
Spot
Toto
Trupanion
VCA CareClub
Wagmo
Other
Policy Number
Referring Veterinarian Information
Our medical team will communicate with the referring veterinarian indicated on the form to ensure continuity of care.
Referring Veterinarian Name
Referring Veterinary Clinic
Referring Clinic Phone
Confirmation and Consent
Please read the important information below and respond on behalf of the primary pet-owner.
Select all that Apply
Active Military/Veteran (with valid ID)
Service Dog (with proof of formal training)
Rescue Group/Shelter (with valid documentation)
Military/Police Animal
Veterinarian
Veterinary Staff Member
None of the above
Social Media Photo Release
*
Yes
No
With your permission, if circumstances are appropriate, we may take photos of your pet for marketing or educational purposes. We do not share personal information including your last name, confidential medical information and communications with your veterinarian. We may identify you and your pet by first name. I grant permission and acknowledge and agree that no sums whatsoever will be due to me as a result of their use.
Consent
*
I have read and agree to the policies below
I consent to an examination of my pet by the providers at Veterinary Specialty Hospital (VSH - NC). I understand that diagnostics and treatment along with the associated costs will be discussed with me prior to delivery and I have the right to decline. If my pet is hospitalized, I understand the provider will present an estimated treatment plan with the associated costs, however, treatment may vary throughout the duration of my pet’s stay. I will be informed of any costs that exceed the initial treatment plan so I am able to make informed decisions about my pet’s care.
I understand that Ethos requires 24-hour notice to reschedule or cancel appointments. Appointments that are not canceled prior to 24 hours may incur a charge equal to the consultation fee.
Payment is due at the time of service and any remaining balance must be paid when services are complete. All day services and hospitalizations require a deposit in full of the estimated cost.
I understand that photos for marketing or educational purposes may be taken of my pet, if circumstances are appropriate. Personal information is not shared including last name, confidential medical information and communications. My pet and I may be identified by first name. I grant permission and acknowledge and agree that no sums whatsoever will be due to me as a result of the use.
I understand that a photograph of my pet for identification purposes is captured and stored in the medical record. This is used identification and is not shared. This photo is compulsory as it ensures proper care for your pet while in our care.
I am the legal owner or representative of the legal owner of the animal being presented and I am 18 years or older.
Signature
*
Please write your name to represent your signature
Phone
This field is for validation purposes and should be left unchanged.
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