Date(Required)

Name(Required)

First Last

Partner/Spouse name

First Last

Preferred number:(Required)

Texting (SMS) okay(Required)

Yes

Address(Required)

Street Address Address Line 2 City State ZIP Code

Secondary Phone

For Secondary phone: Texting (SMS) okay

Yes

Primary email address(Required)

reminder to check spam folder & do not “unsubscribe” from communications with VCC

Secondary email address

Employer

Occupation

How did you hear about us?

Patient Information

Name(Required)

Date of Birth(Required)

Age(Required)

Gender(Required)

Spayed or Neutered?(Required)

Yes

Breed(Required)

Color(Required)

Current medications and times a day given(Required)

Preferred pharmacy(Required)

Current supplements and times a day given(Required)

Your pet’s current diet(Required)

Kibble

Canned

Raw

Home Cooked

Diet

Diet details

Any known allergies to foods or medications:(Required)

Is your pet current on a rabies vaccination:(Required)

Yes

Has your pet had any adverse reactions to any medications:(Required)

Primary veterinarian's name(Required)

Name of primary hospital(Required)

General Informed Consent

I authorize Veterinary Cancer Care, P.C., along with the attending veterinarian and their team, to provide the treatments and perform the procedures discussed with the doctor. I acknowledge that all procedures and treatments carry inherent risks, and I commit to discussing any concerns about those risks with the attending veterinarian prior to proceeding.(Required)

I authorize and acknowledge

I agree to allow only authorized adults (18 years or older) to bring my pet in for treatment and services. Additionally, I understand that Veterinary Cancer Care may adjust fees, with advance notice, for reasons including, but not limited to, industry standards, supply and demand, inflation, contracted medical personnel, and other professional considerations.(Required)

I agree

Financial Responsibility Consent

*Updated January 2025*

I agree to assume full and complete financial responsibility for the balance of ALL services rendered at the time my pet is discharged. This means paying for the associated fees in full by cash, card, or check made payable the same day. I acknowledge that any estimates presented to me are not a guarantee of final charges and agree to pay for all services and treatments provided to my pet. I understand that Veterinary Cancer Care no longer provides in-house payment plans and therefore it is my responsibility to obtain any necessary f inancing from an outside source, confirm the funds are immediately available for use, and know my limits BEFORE authorizing care. I acknowledge that Veterinary Cancer Care has the right to refuse me services should I be unable to provide payment in full. Any outstanding balances that do not have a written payment plan on file, will be required to be paid in full in order to proceed with future scheduling, services, and treatments. Balances cannot be carried forward(Required)

I agree

Social Media Consent

We want your pet to be Facebook famous but we need your permission first.

I grant permission to Veterinary Cancer Care, its employees and authorized representatives to take photographs and/or video of me and/or my pet(s), to copyright, use and publish the same in print and/or electronically. Veterinary Cancer Care may also use and publish my pet’s story, including relevant medical history. I agree that Veterinary Cancer Care may use such photographs, videos or stories including me and/or my pet with or without our names and for any lawful purpose, including for example such purposes as social media, publicity, advertising, and other Web content.(Required)

Yes. I consent.

No. I do not consent. **a warning will be placed on your account should you choose this option**

The 3 R's For Our Clients

Rights

To be treated with respect, compassion, and kindness by our staff and veterinarian(s). To be an active participant in your pet’s healthcare choices. To review & discuss any erroneous entry or omission made on your invoice. There are circumstances where an audit of our day will uncover missing information that is necessary to complete your pet’s medical record. Our hospital administrator is open to discussing any questions you have.

Responsibilities

To ask questions and understand the services being offered and provided. To treat all staff and veterinarian(s) with respect. Offensive or rude behavior will not be tolerated. To share with our medical team any concerns, changes, or adverse reactions your pet has experienced. To clearly communicate your budget to the staff and veterinarian(s). Ask if there are alternatives to fit your budget. Ask the veterinarian to help you prioritize today’s services based on your budget. Request and review an estimate prior to the start of care. (see reminder below regarding estimates)

Reminders

Estimates are only an approximate calculation of services. They are not a final representation of your pet’s invoice. Our wait times can sometimes be extensive. Please ask if there are options, and we will explore that together.

Payment

Cancer care is a specialty service that can require much more diagnostic and treatment time than a general veterinary visit. It is also necessary sometimes to prioritize an urgent or emergent case over those scheduled for other types of care. Payment is due in full at the time of services, including previous balances. Accounts with previous balances will be required to pay in full to schedule new visits or services.

VCC no longer is capable of offering in-house payment plans. You are encouraged to utilize Care Credit. Please apply and know your credit limits prior to services.(Required)

I understand

Animal Housing

Veterinary Cancer Care strives to promote a fear-free environment for our patients by allowing animals who are awaiting treatment or pick up, and who have been determined as having no-risk behavior towards other animals or people, to be housed safely and securely with our front of house staff and other risk-free animal patients, as well as Dr. Kelly’s personal animals. We feel socialization and a cage-free environment help relieve stress and anxiety amongst our patients.

Right to Decline(Required)

I understand that I have the exclusive right to decline cage-free housing of my personal pet and will verbalize this preference clearly to all staff should my pet have to remain in the care of VCC without me being present.

Please select an option(Required)

Yes. I would prefer my pet to be cage-free while at VCC.

No. I would prefer my pet to be in a kennel while at VCC. **a warning will be placed on your account should you choose this option*

Release waiver(Required)

As the client, I acknowledge and understand that my pet will be exposed to and may socialize with other animals in the clinic who are seeking treatment (“Patient Animals”) and the owner, Dr. Kelly’s, personal animals (“Clinic Animals”). Veterinary Cancer Care (“VCC”) takes every precaution necessary to reduce these risks; however, I understand that potential harm could occur to my pet while in the care of VCC, including but not limited to: exposure to parasites, viruses, and other medical conditions passed from animal to animal; sprains, strains, bites, broken bones.

Release waiver(Required)

I further understand that not each and every potential risk from exposure to both Patient Animals and Clinic Animals can be listed but, nonetheless agree that the benefits associated with socialization and a cage free environment outweigh the risks, therefore, I hereby voluntarily release, forever discharge and agree to hold harmless and indemnify VCC and its agents, successors, heirs, from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my pet’s exposure to Patient and Clinic Animals, including those allegedly attributable to the negligent acts or omissions of VCC and their staff.

Release waiver(Required)

I further understand that I may be exposed to certain risks when bringing my pet to the clinic or when picking my pet up from the clinic. Such risks may include property damage, and/or physical injury inside or outside the facility, such as from falling, slipping, illness, and/or dog bites. I agree to forever release and hold harmless VCC, including its owner or employees, agents, successors, and heirs, from all liability, claims, demands, actions, or rights of action, which are related to, arise out of, or are in any way connected with bringing my animal to and from the VCC facility, including those allegedly attributable to the negligent acts or omissions of VCC or their staff.

Vicious Tendencies(Required)

I affirm that I am unaware of any vicious tendencies by my animal towards other animals

Vicious Tendencies(Required)

I affirm that I am unaware of any vicious tendencies by my animal towards people. (If your pet is aggressive towards other animals and people please notify our staff immediately.)

Record Sharing(Required)

I give VCC consent to share my pet’s medical records with other veterinary hospitals or animal related services, as needed.

I HAVE CAREFULLY READ THIS CONSENT, WAIVER, and RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I ACCEPT AND SIGN IT OF MY OWN FREE WILL.(Required)

Sign above

Printed Name(Required)

Client Registration Form

Patient Information

General Informed Consent

Financial Responsibility Consent

Social Media Consent

The 3 R's For Our Clients

Payment

Animal Housing

Make an appointment
with us today!

Patient Information

General Informed Consent

Financial Responsibility Consent

Social Media Consent

The 3 R's For Our Clients

Payment

Animal Housing

Make an appointmentwith us today!

Make an appointment
with us today!