Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

Date of Birth *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

No

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

No

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

By listing your primary care veterinarian above, you are authorizing Veterinary Specialty Center of Tucson to release patient information to the primary care hospital or
veterinarian.

Primary Care Facility *

Primary Care Veterinarian(s) *

By checking this box I understand that I will be required to leave a 100% deposit on the high end of the estimate I am provided. Any unused funds will be refunded to me within 7-10 business days following discharge from the hospital. *

I Agree

By checking this box I understand that I am providing a digital version of my registration form to the hospital and that this form can take 24-48 hours to be processed. I may still be required to complete a physical registration form on site for information accuracy. *

I Agree

By submitting this form, I hereby authorize Veterinary Specialty Center of Tucson to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Veterinary Specialty Center of Tucson.

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New Patient Form

OPTION 1
Complete Online

OPTION 2
Complete on Arrival

New Patient Form

Owner Information

Emergency Contact

Patient Information

Primary Veterinarian Information

Caring for Pets in Tucson

New Patient Form

OPTION 1Complete Online

OPTION 2Complete on Arrival

New Patient Form

Owner Information

Emergency Contact

Patient Information

Primary Veterinarian Information

Caring for Pets in Tucson

OPTION 1
Complete Online

OPTION 2
Complete on Arrival