Intake and Consent

We are excited that you have chosen us to be a part of your pet’s health care. We are dedicated to providing convenient, comprehensive, and cost effective care for your furry family member! This form is intended to collect the information necessary for us to initiate, populate, and maintain appropriate client and medical records, obtain pertinent medical and and historical information about your pet, and collect information regarding billing and collections of unpaid invoices and other financial obligations. By completing this form, you consent to the use of this information for any of the above stated purposes.

Email(Required)

Enter Email Confirm Email

Client Information

Here you will enter a little bit of information about yourself to establish an account with 716Vet

Name(Required)

First Last

Spouse or Co-Owner's Name

First Last

You may enter the name(s) of anyone who may access your pet’s medical records here.

Primary Phone(Required)

Secondary Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Birthday(Required)

Please enter your date of birth here. You will have a chance to enter your pet’s later.

Employer

Please enter the name of your employer here.

CareCredit or ScratchPay

Care Credit

ScratchPay

Do you plan to use CareCredit or ScratchPay for today’s visit? If so, please make us aware here.

Patient (pet) Information

This is where you will enter information about your pet. Please try to be as accurate as possible as many of these questions will help the medical team decide what is the best course of therapy for you pet.

Pet's Name(Required)

Species

Canine

Feline

Other

Breed(Required)

What breed is your pet? If you have a dog, this may be something like Poodle, Labrador Retriever, or Boxer. If you have a cat, this is often domestic short, medium, or long haired – this is based on the length of their fur. If you are unsure what breed your pet is, you can put “unknown”.

Color(Required)

What color or markings does your pet have? For example, you may put ‘yellow’ or ‘tricolor’.

Gender and Reproductive status(Required)

Female Spayed

Male Neutered

Female

Male

Date of Birth or Approximate Age(Required)

Tell us how old your pet is. If you know the exact age, this is helpful but if not, make your best guess.

Primary Veterinarian(Required)

This question is VERY important. What veterinarian does your pet normally see for vaccines and wellness visits? This will help us communicate quickly with your veterinarian so that they know what is happening with your pet.

Pet Insurance(Required)

Do you have pet insurance? If so, please list the company and policy number below. If no, Write “na”

Presenting Complaint(Required)

Why is your pet here today? Write as much as you like. The more details the better. Tell us anything out of the ordinary. Are they eating and drinking normally? Urinating and defecating? Are they vomiting or have diarrhea? How much and when? If they have an injury, when/how did it happen? Any coughing or sneezing?

Other Information

This is where people let us know if their pet is nervous or likes to use their teeth for something other than food.

Where did you hear about 716Vet?(Required)

My Primary Care Veterinarian Sent Us To 716VET

Someone Told Me About 716VET (Friend, Family, Co-Worker, etc.)

Online – Search Engine (Google, etc.)

Online – Social Media (Facebook, Instagram, Twitter, etc.)

Online – Banner Ads

Radio

Television

Drive By

Other

General Consent for Care and Treatment Consent(Required)

I AGREE TO THE TERMS AND CONDITIONS

TO THE CLIENT: At this point in your pet’s care, no specific treatment plan has been recommended. This consent form is simply intended to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). I understand that the cost of examination will be charged once a nurse or staff member begins collecting information about your pet whether a doctor examines your pet or not. Once examined, you will be informed about the condition of your pet and any recommended surgical, medical or diagnostic procedures to be used so that you may make the decision whether or not your pet should undergo any suggested treatment or procedure. You should always ask about any risks and hazards involved in any recommended diagnostic, therapy, or procedure.

This consent provides 716Vet with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you are of legal age to enter into a contract in New York, (2) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (3) you consent to treatment at this office or any other office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your veterinarian about the purpose, potential risks and benefits of any test, therapy, or procedure ordered for your pet. If you have any concerns regarding any test or treatment recommended by your veterinarian, we encourage you to ask questions.

716Vet strives to protect the information it collects. You understand that your signature releases 716Vet from all liabilities associated with theft of this information by any entity, including but not limited to all consequential damages. Requests for medical records may be made by other owners, veterinarians, insurance companies, or other entities. By signing this for you authorize 716Vet and it’s employees to release information they believe necessary for the continued care, therapy, and treatment of your pet. This may mean that your pet’s medical record is shared with 24-hour/ER facilities, specialty facilities, and other entities.716Vet also reserves the right to use information collected about your pet for research and educational purposes. Unless required by law, medical records will NOT be released without proper authorization from you or your agent if requested from an outside entity not associated with your pets care. You may have to sign additional forms to authorize release of those records.

716Vet encourages the use of pet insurance to help with the cost of the healthcare of your pets. 716Vet will digitally provide all records to any authorized entity associated with your account as requested. You acknowledge that 716Vet is NOT responsible for filing, completing, or verifying and paperwork associated with an insurance claim. 716Vet is not liable for the decisions, practices, or failure to perform of any insurance provider.

716Vet does not house, board, or care for patients without owners present or overnight. Any pet left after close of the facility will be transferred to the local municipal animal control entity as an abandoned animal. You understand that failure to collect an animal does NOT waive the financial obligations accrued through the performance of diagnostics, treatment, hospitalization, and other care given.

You also acknowledge that payment is due at the time of service. Billing is NOT offered through 716Vet (or its subsidiaries) in any form. For hospitalized cases and cases requiring a procedure be performed, a deposit is required in advance. The balance is due upon discharge from the hospital. You may pay with cash or accepted credit cards, CareCredit, ScratchPay. We do not accept personal checks.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location Map

(716) 949-0161

Hours of Operation