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6 Tips for a Stress-Free VIRMP Application Process
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About Us
About Us
Executive Team
Our Hospitals
Advancing Medicine
Meet Our Medical Leadership Team
Medical Excellence
Medical Operations
New Product Committee
Specialty Advisory Board
Veterinary Science Consultancy
Clinical Studies
Open & Enrolling Studies
FAQs: Clinical Studies at Ethos
Ethos Discovery
Ethos Updates
Careers + Development
Ethos is Hiring
Career Opportunities
Employee Benefits
Meet Our Talent Teams
Referral Programs
Learning & Development
VetBloom
Veterinary Nursing Programs
ER Immerse Nursing
Approved Veterinary Assistant (AVA) Program
RECOVER Certification
Fear Free Certification
Veterinary Student Programs
Vet Student Externships
Careers Unleashed
Veterinary Programs
Internship and Residency Programs
ER Immerse
ER ABVP
6 Tips for a Stress-Free VIRMP Application Process
Veterinary Conferences
Veterinary Teams
Ethos Discovery
Clinical Studies
VetBloom CE
Ethos is Hiring
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Client Registration
Step
1
of
5
20%
Ethos Veterinary Health Hospitals
Select the Ethos Veterinary Health Hospital at which you are seeking Treatment
*
Please Select
Boston West, Natick, MA
Bulger, Lawrence, MA
Capital District, Latham, NY
Mass Vet, Woburn, MA
Peak, Williston, VT
Port City, Portsmouth, NH
Premier – Chicago, IL
Premier – Grayslake, IL
Premier – Orland Park, IL
SAVES, Lebanon, NH
VSH – North County, San Marcos, CA
Vista, Sacramento, CA
VSH – Sorrento Valley, San Diego, CA
WVRC - Grafton, WI
WVRC - Racine/Kenosha, WI
WVRC - Waukesha, WI
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
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
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
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
*
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
*
Neutered Male
Intact Male
Spayed Female
Intact Female
Species
*
Cat
Dog
Other
Species, if Other
Bearded Dragon
Chinchilla
Ferret
Gecko
Gerbil
Guinea Pig
Hamster
Hedgehog
Rabbit
Rat
Tortoise
Turtle
Bird, Reptile, or Something Else
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
*
None/Don't know
24PetWatch
AKC Pet Insurance
ASPCA Pet Insurance
Embrace
Fetch - (formerly Pet Plan)
Figo
Hartville Pet Insurance
Healthy Paws
Lemonade
Nationwide Pet Insurance (VPI)
Pet Assure
PetFirst (MetLife)
Pets Best
Prudent Pet
Pumpkin
Spot
Toto
Trupanion
Wagmo
Other
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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