Welcome to Urban PetRx! We are happy you have chosen us as your primary care provider for your pets. We are dedicated to providing exceptional patient care and service. Our goal is to be uniquely transparent regarding our fees and the care we provide. Please ask us if you have any questions concerning the treatment of your pets or policies of the clinic.

Primary Owner or Agent Name

Name *

First

Last

Pets Name *

Email *

Place of Employment *

Primary Phone *

Secondary Phone

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Is anyone else other than yourself or Urban PetRx, authorized to make medical decisions or approvetreatments for your pets?

please provide further information below *

Other/Co-Owner or Agent Name (if applicable) #1

Name *

First

Last

Email *

Place of Employment *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

What is your relationship with the above? *

Other/Co-Owner or Agent Name (if applicable) #2

Name *

First

Last

Email *

Place of Employment *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

What is your relationship with the above? *

Communication Preferences

It is helpful to know your preferred ways to communicate with our practice regarding your pet’s care and clinic news. We will do our best to communicate with you in your preferred way(s). Please circle your communication preference for each statement in the table below as ‘Yes’, preferred, or ‘No’, not preferred. We will do our best to follow your communication preferences. CHOOSE ONLY ONE option per statement.

I would like to receive email reminders about my pet’s care. This may include vaccine reminders, appointment reminders etc.

Please send email reminders to my designated Co-Owner or Agent.

I would like to receive text messages about my pet. This may include pet updates while under our care, pre-appointment check-in, remote payment, reminders regarding recommended rechecks or wellness appointments, etc.

I would like to receive invoices by email for remote payment.

Insurance

Do you have pet insurance?

Please note provider

Would you like further information regarding pet insurance?

Previous Veterinarian Information

Name *

First

Last

Hospital

City

How did you find out about our practice?

Authorizations and Acknowledgements

By initialing each box below, you agree and acknowledge each statement.

Indemnification and Assumption of Risk *

As a condition of receiving our services, you, and any guests you bring with you, agree to indemnify us against all claims, liabilities, losses, damages, suits, costs and expenses, including reasonable attorney’s fee, relating to our services to you, except to the extent that such a claim is caused by our gross negligence or willful misconduct. Furthermore, you agree to assume all risks of property damage, injury (such as bites and falls), and death associated with the services that we provide you. The terms of indemnification and assumption of risk shall survive the expiration of this agreement.

Medical Record / History *

I authorize Urban PetRx the ability to obtain all medical records pertaining to my Pet, where my Pet has been previously seen or treated. I understand it is my responsibility to alert the Urban PetRx team regarding previous care facilities to ensure continuity of care.
I understand if I seek care outside of Urban PetRx, it is my duty to update my Pet’s records to ensure my Pet’s records, including but not limited to medications, supplements, diagnostics, diagnosis and medical treatment are kept accurate at Urban PetRx.
I authorize Urban PetRx to release any part of my Pet’s medical records including but not limited to vaccine history, diagnostic results and full medical history, as requested by groomer’s, boarding facilities, day care centers, rehabilitation practices, specialty centers, referral partners and other veterinary clinics/hospitals/practices etc.
Urban PetRx strives to maintain complete and accurate medical records/historical accounts of your Pet(s) medical history. In so doing, email communication(s) and/or a summary of inperson or phone call communication(s) often become part of your Pet’s medical record/history

The Veterinary Client Patient Relationship (VCPR) *

I understand that one of the most important criteria for the delivery of meaningful and collaborative veterinary medical care from the veterinarians and team members at Urban PetRx is polite, effective, comfortable, and open communication. Abusive speak, lewd or aggressive behavior and threats (physical or otherwise) to any team member will not be tolerated.
I understand at minimum, an annual examination with a veterinarian at Urban PetRx is required to maintain a valid Veterinary Client Patient Relationship at our facility. Please see: www.avma.org for more information regarding the VCPR.
I understand Urban PetRx may (i) refuse services or (ii) terminate the Veterinary Client Patient Relationship (VCPR) for any reason, or no reason.

Payment Guarantee and Agreement to Pay *

I understand that payment is due, in full, at the time services are rendered and I assume total financial responsibility for all costs of services rendered for my Pet(s) at Urban PetRx.
I hereby understand that Urban PetRx only accepts (i) cash; (ii) major credit cards; (iii) debit cards; and (iv) third-party payment plans. Payment plans are subject to express approval of third-party vendors.
Urban PetRx is happy to provide information regarding its services and estimates of accrued and anticipated costs. If I have specific questions about costs, I understand I must ask.
Optional: We ask that you keep a current credit card on file with Urban PetRx and that your information may be saved in our system with your consent at first checkout. By providing your credit card information, you authorize us to charge unpaid balances and fees of any kind to this card. For your convenience, we will save this credit card information in your file for future charges.
For any reason payment is not completed at the time of services, Urban PetRx may seek legal action for collection of my debt. Whether or not legal action is needed for collection, I agree to pay Urban PetRx all fees associated with collection of my debt.

Informed Consent for Treatment *

I certify that I am at least eighteen (18) years of age
I am the legal owner (or authorized agent of the owner) of my registered Pet(s) at Urban PetRx.
I hereby authorize and direct Urban PetRx, its Veterinarians, technicians, assistants, and client attendants to perform services, procedures, diagnostics, vaccinations, treatments, medical care and/or administration of medications including extra label and compounded medications as deemed necessary or advisable in connection with or relating to the matters described in an estimate or the matters that have otherwise been explained to me by the Urban PetRx Veterinarian or its team member.
I hereby authorize Urban PetRx to provide veterinary care to the Pet(s) I have registered under my ownership or those Pet(s) I have directed to do so by an authorized agent. I acknowledge that I, or the agents declared by me in this agreement or my Pet’s guardians communicated by other means, upon consultation with the veterinarian, are responsible for the decisions regarding veterinary care of my Pet(s).
I understand that in life-threatening situations, stabilizing care may be instituted immediately upon arrival or without my express consent regarding care provided and their associated costs.
I understand that veterinary care may include, but is not limited to, examination, prescription of medication (including the prescription of extra label and compounded medications as deemed necessary or advisable), or administration of medication (including administration of extra label and compounded medications as deemed necessary or advisable), diagnostics, medical, and surgical care.
I understand that I will need to pick my pet up by the end of the business’ closing day, if I choose not to pick my pet up, an overnight fee may be assessed. I understand that if my pet does need to stay, that there will not be a physical person in hospital overnight and during most weekend hours, as long as my Pet is, within reason, deemed appropriate to be left unattended. This includes acceptance, by me, for unforeseen risks or injury when my Pet is unsupervised. In the event my Pet is deemed inappropriate to be left alone overnight and I am unreachable, my Pet will be transferred to the nearest 24 hour facility at my cost, including but not limited to travel fees, fees for time incurred by our team members and the fees of the emergency clinic. If I am unreachable and neglect to pick my pet up within 7 days with, or without contact, Urban PetRx will assume abandonment and the Hospital will be authorized to take steps to make permanent arrangements for my pet as an abandoned pet.
I understand that a veterinarian may not be in the hospital at all times. I understand that veterinary technicians and/or assistants may perform certain functions in preparation and care of my Pet, even when a veterinarian is not present within the scope of Illinois state laws.
I agree to allow Urban PetRx and its affiliates the ability to walk my Pet(s) outside and I accept any risks in doing so.
I understand and agree that portions of my visit may be recorded for safety and educational purposes. These recordings will not be used for Marketing purposes or as outlined in the, “Urban PetRx Photographic/Video Release & Authorization for Marketing” form unless express authorization is provided on that form.
While I accept that all procedures will be performed to the best of the abilities of the staff and Doctors at Urban PetRx, I understand that no guarantee or warranty has been made regarding the results that may be achieved for my Pets’ care.
I understand that there is a risk of complications with every procedure, including the possibility of death as a severe complication of surgery, anesthesia or other procedures. I also understand that there is no guarantee as to the results of any procedures, diagnostics, vaccinations, or treatments.
I understand that I may ask any questions that I have regarding any procedure, diagnostic, vaccination or treatment recommendations by the Urban PetRx veterinarian or its health care team member before it is performed, except as noted in rare urgent/emergency cases. If something is not clear to me regarding services before them being provided or estimated costs before accrual, I understand I must ask.

I have read and understood this document (Pages inclusive of 1,2,3,...all), including the policies of Urban PetRx. I have truthfully, without duress and to the best of my knowledge, provided the information requested. I am bound by this document. *

I Agree

Print Owner/Agent Name *

First

Last

Date *

Signature *

Clear Signature

new client registration form

Save time during your next appointment! Complete your required new client registration form online from any device at any time before your visit.