New Client/Patient Referral Form

SHERIDAN ANIMAL HOSPITAL
2288 Sheridan Drive • Buffalo, New York 14223
Telephone (716) 833-5345 • Fax (716) 833-8525

Please note: This form should be completed and submitted by the client.

Client Information

Owner's Name*

Email Address*

Home Phone Number

Cell Phone Number*

Street Address

City, State

Zip Code

Occupation:*

Employer:*

Work Phone #:

Significant Other/Co-Owner

Significant Other/Co-Owner's Name

Email Address

Home Phone Number (if different)

Cell Phone Number

Street Address (if different)

City, State

Zip Code

Occupation:

Employer:

Work Phone #:

Others Who Should Be Listed on the Account

Children you may want listed on account:

Emergency Contact First and Last Name:*

Relationship to Contact:*

Contact Phone #:*

Pet Information

Name

Sex
MaleFemale

Species

Breed

Color

Date of Birth/Approximate Age

Approximate weight:

Please note: To be admitted into our surgical suite your pet MUST be current on rabies and dhpp vaccine, unless your veterinarian has exempt them from these vaccines for medical reasons. If this is the case we will need and exemption letter from your veterinarian.

My pet received a rabies vaccine on:

And is good until:

My pet received a dhpp vaccine on:

And is good until:

Referring Veterinary Information

Veterinarian my pet is being referred to:

Veterinarian referring my pet:

The referring animal hospital*

Animal hospital phone #*

My pet’s regular veterinarian, if different than who is referring:

Do you have a disk with images or radiographs?
YesNo

Payment Information & Release

Medical History: I give Sheridan Animal Hospital permission to contact previous veterinarians for my pet’s written medical history.

Photo Release: As the owner of record, I hereby grant to Sheridan Animal Hospital, the right and permission to use any photographs/video they have taken of me or my pet for any purpose and in any and all media now or in the future. I hereby grant to Sheridan Animal Hospital the right and permission to use my name in connection with the photographs if they choose. This release serves as a waiver for you as the pet owner of all royalties. I hereby release and discharge Sheridan Animal Hospital, from any and all claims and demands arising out of or in connection with the use of the photograph/videos, including any and all claims for libel or invasion of privacy. I am of adult age, and or the legal guardian of the mentioned minor, and have the right to contract in my own name. I have read the photo release and fully understand the contents. This release shall be binding upon me and my heirs and legal representatives.

Estimates & Deposits: It is understood that an estimate of charges will be given for services. A deposit prior to any treatment will be required at the time of admission. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible, should complications occur. No guarantee or assurance can be made as to the results that may be obtained.

Payment & Fees: Professional fees are to be paid at the time services are performed. Sheridan Animal Hospital reserves the right to charge $25.00 for any missed appointments without 24 hour notification.

I understand and agree that in case of non-payment I will be subject to all billing and/or finance charges associated with my account. Should it become necessary to settle my account through a collection agency or attorney, I, the undersigned agree to pay all costs of collection.

Referral Policy

Your pet has been referred to Veterinary Specialists of Western New York by your veterinarian for medical diagnostic procedure and/or surgical treatment. We will complete these procedures and forward all pertinent information to your veterinarian.

In the event that your pet requires medical help in the future for a problem unrelated to what you were referred for, we ask that you call your veterinarian. The knowledge and familiarity with your pet makes your veterinarian best qualified to manage further conditions. We will treat only your pet’s referred problem to completion. Our commitment to the Western New York veterinary community will not allow us to accept this pet as a patient of our general practice.

YesNo

By selecting yes, typing my name, and submitting this form, I agree to the terms outlined above regarding my pet's medical history, photo use, service payment, and referral terms.

First & Last Name of Owner:

Today's Date