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Veterinary Teams

Client Registration

Step 1 of 5

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Ethos Veterinary Health Hospitals
Select the Ethos Veterinary Health Hospital at which you are seeking Treatment*
Please select the hospital where you are planning to receive treatment from the dropdown list above. The hospital team do not have access to other hospitals' registration forms. Selecting the wrong hospital, or no hospital, will require you to fill the form out a second time. Thank you for your kindness and understanding.

Owner Information
Title*
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*
Zip Code*
Preferred 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
Secondary Phone Number
Phone Type
- Mobile
- Home
- Work

Co-Owner/Alternate Contact
Co-Owner Title
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*
Date of Birth or Age of Pet*

Please enter the number of years (7 years), or enter the date of birth in the format: mm/dd/yyyy.
Sex of Pet*
Species*
Species, if Other
What type of bird or other Species of animal?
Breed*
Color*
Date of Most Recent Rabies Vaccination
MM slash DD slash YYYY
Dates of Other Recent Vaccinations
Vaccine Name Date (mm/dd/yyyy)
Pet Insurance Carrier*
Please specify if Other
Policy Number

Referring Veterinarian Information
Our medical team will communicate with the referring veterinarian indicated on the form to ensure continuity of care.
Primary Care Veterinarian Name

Name of the veterinarian who provides your pet's routine veterinary care.
Primary Care Veterinary Clinic*

Where do take your pet for routine care? If you do not know, or don't have one, please say "none".
Primary Care 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 this Ethos Veterinary Health hospital. 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

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Veterinary Teams

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