Vista Veterinary Hospital - New Patient Form

VISTA VETERINARY HOSPITAL
Dr. Kathy Batdorf - Dr. Matthew Stidham - Dr. Geoffrey Goebel

Dr. Marni Hamack - Dr. Michelle Meyer - Dr. Michelle Bouchey

Thank you for choosing Vista Veterinary. In order to have complete records and so we are able to contact you in an emergency, please complete the following:
Owner's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Enter phone numberFormat: (000) 000-0000.
Alternate Phone Number
Enter phone numberFormat: (000) 000-0000.
Phone Number
Enter phone numberFormat: (000) 000-0000.
Email
Co-Owner or Spouse's Name

First NameLast Name
Co-Owner or Spouse's Phone Number

Area CodePhone Number
Client DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like an authorized agent added to your account? Must be at least 18 years of age
authorized agent's Name

First NameLast Name
authorized agent's Phone Number

Area CodePhone Number
Pet's Info
Pet's Name
Species
Breed
Birth Date
Color
Diet
Sex
Spayed or Neutered?
Is your pet on any Medication or supplements? What kind?
Markings
Microchip / Microchip #
Diet
Treats
Food Allergies
Dogs - Date of Last Vaccines:
Distemper/Parvo
Bordetella (Kennel Cough)
rabies
Cats - Date of Last Vaccines:
Distemper (FVRCP)
FELV (Feline Leukemia)
Cat: Rabies
Any specific Problems that we should be aware of before the appointment?
Any underlying medical conditions?
How did you hear about us?
If you were referred to us, by whom?
Previous Veterinarian where past records could be obtained if necessary
Payment Information:

Payment is due when services are provided
Brand new clients to Vista Veterinary Hospital will be required to make a deposit at the time of appointment scheduling. This deposit will be non-refundable and non-transferrable.
Method of Payments :
How did you learn about us?
Which telephone book?
Whom?
I agree to allow Vista Veterinary Hospital to use my name, my pet's name, and photographs of myself and/or my pet(s) for any lawful purpose including publicity, illustration, advertising and appearances on our website or social media platforms.
Consent for Audio Recording and Transcription

I acknowledge that Vista Veterinary Hospital uses a dictation software audio recording) for improved medical record keeping with the assistance of AI transcription. This software will be used for:
- Phone communication by a doctor or other Vista employee
- Appointment (SOAP notes) by a doctor or other Vista employee
Consent for Audio Recording and Transcription Signature
CPR/Resurrection Authorization

If your pet's heart stops beating and/or your pet stops breathing while at ourhospital, the veterinary team may recommend cardiopulmonary resuscitation (CPR).

CPR can sometimes restore a heartbeat and breathing; however, CPR is not always successful. Even when successful, there may be significant underlying illness or injury and additional treatment, hospitalization, or referral may be necessary. Please select one option to indicate your wishes. Your selection will be saved in your pet's medical chart.
CPR/Resurrection Authorization
If my pet experiences cardiopulmonary arrest, I authorize the veterinary team to perform CPR and provide emergency resuscitation measures as medically appropriate.

I understand that CPR and emergency treatment may result in additional charges.
If my pet experiences cardiopulmonary arrest, I do NOT authorize CPR or resuscitation attempts.

I understand that if my pet's heart stops beating and/or my pet stops breathing, the veterinary team will provide comfort and end of life care as indicated but will NOT attempt CPR.
CPR/Resurrection Signature
Should be Empty:

Pet's Info

Dogs - Date of Last Vaccines:

Cats - Date of Last Vaccines:

Payment Information:

Consent for Audio Recording and Transcription

CPR/Resurrection Authorization