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Hospitalization Form

The Doctors and Staff welcome you and thank you for choosing Bishop Ranch Veterinary Center for the care of your pet. We look forward to providing you with the highest level of care. We are very conscious of your right to privacy regarding the information you provide for us. We use this information only to help serve you better and we do not disclose this information to any third party vendors or Internet businesses. No information will ever be disclosed to outside parties. Please provide us with the following information.


Contact Information
First Name
Last Name
Phone Number
Email Address
Street Address
City
State:
Zip:
Employer
Employer Phone

Secondary Contact

First Name
Last Name
Phone Number
Email Address
Employer
Employer Phone

Preferences

Would you like to receive our Monthly Email Newsletter?
Yes
No
Would you like to receive text messages for pet updates?
Yes
No
Would you like to receive Email vaccination reminders?
Yes
No
How did you hear about our hospital? (Check all that apply)
Friend/Relative
Yellow Pages
BRVC Website/Internet
Advertisement
Coupon
Area Hospital
Rescue Group
Sign
Event/Street Fair
News Story

Pet Information
You have the right to consent to or refuse any proposed surgery or medical procedure at any time prior to its performance. Bishop Ranch Veterinary Center & Urgent Care maintains personnel and facilities to assist your pet′s veterinarian in the performance of various surgical and therapeutic procedures. These procedures may involve unsuccessful results, complications, injury or even death from both known and unforeseen causes, and no warranty or guarantee is made as to results or cure.

Previous Veterinary Hospital
Permission granted for release of records
Yes
No


Pet #1

Name
Gender
DOB/Age
Type of Animal
Breed
Spayed/Neutered
Yes
No




Additional Notes or Comments
Financial Responsibilities
All fees are due at the time services are rendered. Payment in full is expected at the time of Check Out. In the event that your pet is hospitalized with on-going treatment you will be presented with an estimate for cost of treatment and a deposit will be required at that time. You will be advised daily of your account balance. Accounts with outstanding balances are subject to a monthly $3 billing fee and a monthly finance charge of $3.00 or 1.5% of the outstanding balance whichever is greater.
I Agree


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