Oncology Client Form

Client Information

Primary Owner's Name

Prefix First Last

Secondary Owner's Name

Prefix First Last

Address

Street Address Address Line 2 City State Zip Code

Primary Phone

Secondary Phone

Primary Email

Secondary Email

Best Number to Reach You

Primary Phone

Home Phone

Work Phone

Primary Provider Information

Primary Vet Clinic

Veterinarians Name

Primary Vet's Email

Primary Vet's Phone Number

Additional Clinics Recently Visited

Patient Information

Pet Name

Date of Birth

How long have you owned your pet?

Species

Dog

Cat

Reptile

Exotic

Breed

Gender

Male

Female

Spayed/Neutered?

Yes

If Spayed/Neutered, at what age?

Do you have other pets in the house?

Yes

Is your pet primarily indoor or outdoor?

Indoor

Outdoor

Both

Previous and/or ongoing medical problems or issues?

Does your pet have any known allergies or adverse reactions to medications?

What is your pets current diet?

Does your pet have any food allergies?

What are your pets current medications/supplements?

What are your goals for your pets consultation?

Please upload photos and files you would like to share (5 file maximum).

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Photo Consent

I hereby grant Wake Veterinary Medical Center permission to take photographs of my pet(s), and to publish those photographs for any lawful purpose, including but not limited to their website, social media accounts, and promotional materials either digital or in print, in perpetuity. I understand that Wake Veterinary Medical Center will not use my name or my pet's name.

By electronically signing this form I authorize Wake Veterinary Medical Center to edit and share the photograph(s) mentioned above. I also waive any rights of privacy or compensation associated with the use of my pet(s) image(s) for the personal or commercial purposes outlined above.

Photo Consent Agreement

I agree to the photo consent and usage above

I hereby consent to and authorize the provision of medical evaluation, treatment, and care by Wake Veterinary Medical Center as deemed necessary. I understand that such care may include examinations, diagnostic procedures, and routine treatments. I acknowledge that I have the right to ask questions and to refuse any treatment at any time, and that no guarantees have been made regarding the results of care.

Evaluation and Treatment Agreement

I agree to the Evaluation and Treatment above

Electronic Signature(Required)

Date(Required)

Client Information

Primary Provider Information

Patient Information

Wake Veterinary Medical Center

Primary Care Hours:

EMERGENCY: OPEN 24 HOURS EVERY DAY