Primary Contact

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Do you agree to receive text messages from Villa Rosa Veterinary Hospital? *

I agree

By checking this box, you consent to receive informational and/or promotional text messages from Villa Rosa Veterinary Hospital at the number provided, including messages sent by the autodialer. Consent is not a condition of purchase. Message & data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. Privacy Policy.

Email *

Occupation

Preferred Method of Contact

Phone call
Text
Email

Secondary Contact

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Secondary Phone

Email

Occupation

Authorized to treat pet?

Yes
No

How did you hear about us? *

How much information do you want to be given about your pet’s health?

I want a full explanation—anything and everything.
I want a brief explanation—just the important stuff.
I just want to know if there’s anything I need to do—keep it simple.

Patient Information

Pet's Name *

Dog or Cat *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have any known or suspected allergies? *

Yes
No

Has your pet ever had an adverse reaction to any vaccine or medication? *

Yes
No

Current diet/treats:

Please list any medications your pet is currently taking, including heartworm/flea prevention and supplements.

Please list any previous medical issues, surgeries, or major illnesses your pet has experienced.

Does your pet have any behavior issues that you would like to discuss, or that we should be aware of?

Do you have pet insurance?

Yes
No

Provider Name

At Villa Rosa Veterinary Hospital, we implement Fear Free techniques whenever possible. We are committed to reducing stress and creating a positive experience for your pet. We often use many forms of treats to distract and entice our patients. However, we understand that some patients have food sensitivities, allergies,
or a sensitive stomach.

Please indicate if you consent to our staff providing various tasty treats during your pet's visit:

Yes
No

We believe in preventing and alleviating fear and anxiety during veterinary visits through the use of low-stress handling, pheromones, and treats/toys. In some situations, calming supplements, anxiety medications or pain relief will be prescribed, and we may ask that you reschedule your pet’s exam (if non-urgent) to allow for these therapies to work. We understand this may be an inconvenience, and only offer this recommendation in the best interest of your pet. Please feel free to discuss any concerns or questions regarding these practices with our team.

Payment is due in full at the time of service. If your pet is admitted into the hospital, a deposit may be required. We accept Cash, Visa, MasterCard, Discover, and CareCredit payments. We neither extend credit, nor bill for services. *

I have read and accept the financial policy.

Scribble Vet Consent and Release

Our veterinary hospital uses Scribble Vet, a system designed to enhance clinical documentation by recording your pet’s appointments. To proceed with recording, we need your consent. By signing this form, you agree to the following:

1. Appointment Recording

You consent to the recording of your pet’s veterinary appointments.

2.Usage Rights

You grant us permission to use and share these recordings, as well as any other materials you provide, for the purpose of improving clinical documentation and enhancing the quality of care we
provide.

3. Age Confirmation and Understanding

You confirm that you are at least 18 years old and fully understand and accept the terms of this consent agreement. We are dedicated to providing the highest standard of care for your pet in a way that is comfortable for you both.

Name *

Client’s Signature *

Clear Signature

Date *

Online Forms

New Client Registration Form

Primary Contact

Secondary Contact

Patient Information

Scribble Vet Consent and Release

1. Appointment Recording

2.Usage Rights

3. Age Confirmation and Understanding

Ready to Visit?

Have a Question?

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Contact Information

Hours

Emergency Care