New Patient - (Current) Step 1 of 3 33% Owner InformationOwner's Name* First Last Members of the family that are permitted to bring your pet(s) for treatment. Must be at least 18 years old.Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone #1Cell Phone #2Spouse Name Spouse PhoneEmployer Name Work PhoneEmail* Email Address Confirm Email Preferred Contact MethodPhoneTextEmailHow Did You First Become Aware Of Our Clinic?*Choose One...Personal RecommendationAnasazi WebsiteDexonlineYellow PagesPrevious ClientEmergency Hospital or other VetAnimal Care & ControlDrove ByPet StoreYelpOtherWhom Should We Thank? Please Specify Subscribe Please subscribe me to the FREE Pet Living & Wellness Newsletter Interested In Dogs Cats Horses Birds Reptiles Rodents Dr/Member Announcements Select Topics of InterestThe policy of Anasazi Animal Clinic is to provide an estimate of charges for any case where in-hospital treatment, surgery or hospitalization will be provided. Please feel free to discuss any fees prior to services rendered. Pet InformationList of Pets Pet's Name Species This Pet's Sex Actions Edit Delete There are no Pets. Add Pet Maximum number of pets reached. Visit InformationAppointment Date* MM slash DD slash YYYY Appointment Time* : Hours Minutes AM PM AM/PM Previous Veterinarian* Reason for Visit* Duration of Problem* CONSENTS: I authorize and direct the veterinarians at Anasazi Animal Clinic and East Valley Animal Clinic to examine, diagnose, prescribe, perform therapeutic procedures, and/or surgery that their judgment may dictate to be advisable for the patient's well-being. No warranty or guarantee has been made as to the result or cure. Payment is required at the time of services. We accept cash, all major credit cards, and Synchrony CareCredit and Wells Fargo Advantage with the required identification. Care Credit and Wells Fargo are leaders in patient financing offer interest-deferred and low-interest options for qualified applicants. Ask the front desk for more information on this option or for an application. If you have any questions about the fees or the financial policy, please alert a staff member before services are performed. Accounts not paid within 30 days are subject to an interest finance charge. In the event any balance due is not paid as agreed, the undersigned jointly and severally agrees to pay all cost included in the unpaid balance, including a reasonable collection and /or attorneys' fees.* I have read and understand the financial policyI hereby irrevocably consent to and authorize the use and reproduction of any and all photographs or radiographs taken of my pet without further compensation to me by Anasazi Animal Clinic and East Valley Animal Hospital, or anyone authorized by Anasazi Animal Clinic and East Valley Animal Hospital or their partners or associated business entities for marketing purposes. All negative, positive, and digital images together with the prints shall constitute Anasazi Animal Clinic and East Valley Animal Hospital property, solely and completely.* Yes No When drugs are FDA-approved for use in one species but are administered to species other than those for which they have been approved and labeled, the terminology is that the drugs are being used in an "extra-label" manner. Extra-label use does NOT include the use of experimental drugs or drugs manufactured in foreign countries that have not been approved by the FDA. Because few drugs are labeled for use in small animals, most drugs administered by small animal or exotic animal veterinarians, including antibiotics, anesthetic agents, and other medications, are routinely used in an extra-label manner. This is within the standard of care, but good medical practice requires that owners be advised when drugs are being used in an extra-label manner.* I authorize the staff at this veterinary practice to administer and prescribe extra-label drugs for my pet. I understand that any drug, including those that are used in an extra-label manner, can produce undesirable side effects. Thus, I acknowledge that it is my responsibility to administer prescribed medications for my pet as directed and to notify my veterinarian of any apparent side effects or complications.We are a fear free facility. Fear free sometimes includes a sedative being sent home with your pet in order to give him/her a more positive experience and our staff a safer one. We are more than willing to take our time with each patient in order to provide the most positive experience possible but we are unwilling to sacrifice safety to do this. We appreciate your understanding. * I understandA deposit may be required once an appointment is scheduled and will be non-refundable if the appointment needs to be cancelled and is not cancelled 24 hours before appointment Tues-Sat and 48hours for Monday appointments or holidays.* I understand.I hereby certify that I am the parent/guardian/owner of pet(s) listed on this form* I do give my consent without reservations to the foregoing on behalf of him/her/them.I am aware that Anasazi Animal Clinic and East Valley Animal Hospital rely on the information provided above to determine the correct course of treatment for my pet. I testify that the above information is true to the best of my knowledge. I recognize that I am responsible for payment of all services provided during my visit.Signature of Responsible Party* First Last Must be over 18 years of age.Today's Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
