Make an Appointment | Florida Veterinary Referral Center

Please ensure to carefully complete this entire form, including the “CAPTCHA” check-box at the end before hitting “submit”. Required responses are marked with an asterisk (*).

Owner Information
Owner(s) Full Name*
Email Address*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
Other Phone
Residential Status*
Patient Information
Pet's Name*
Type of Animal*
- Dog
- Cat
- Other
Breed*
Gender*
- Male
- Female
Spayed/Neutered?*
- Yes
- No
Age or DOB*
Color*
Reason for visit today?
Primary Veterinarian Information
Doctor's Name (write N/A if no answer)*
Hospital Name (write N/A if no answer)*
Address
City State / Province / Region
Phone
Please note referring doctor, if different from primary doctor (write N/A if no answer)*
Hospital Name, if different from primary doctor (write N/A if no answer)*
Address
City State / Province / Region
Another veterinarian you have seen, please name here
Hospital Name
Address
City State / Province / Region
How did you hear about us?*
- My Veterinarian
- Community Event/Magnets
- Mailings
- Friend/Family
- Google or Internet Search
- Social Media/Facebook
- Other
Please carefully review our payment and admission policy detailed below. By entering your name and submitting this form, you are agreeing to Florida Veterinary Referral Center's terms and conditions listed below.

Payment Policy

Thank you for choosing Florida Veterinary Referral Center. We are committed to the success of your pet’s medical treatment and care. Please understand that payment of your bill is part of this treatment and care.
Payment for outpatient services is due at the time of service. Inpatient (hospitalization) services require the low end of your estimate range as a deposit for treatment and care. Complete payment of the total balance is due upon the discharge of your pet from our center.
We accept payment by Cash, Debit Card, Visa, MasterCard, American Express, and Discover. We do not accept checks.
For our clients who wish to utilize an extended payment plan, we participate in both the Wells Fargo Health Advantage and CareCredit programs which are subject to prior credit approval. An application for either program can be processed through our front office within minutes. If approved, today’s services can be charged to your new account.
If you need further information about any of these policies, please ask to speak with the Office Manager or Hospital Manager.
I am fully aware that all charges for the services provided are my responsibility. I agree to pay all charges incurred by my pet at the time of his/her release. Late payments are subject to a late charge of 1.5% every 30 days or less. All collection costs and reasonable attorney’s fees are my responsibility.
By signing below, I affirm that I understand the information provided to me and accept responsibility for any bill incurred during my pet’s visit to Florida Veterinary Referral Center & 24-Hour Emergency and Critical Care.
I fully understand that no guarantee of successful treatment is made and will not hold Florida Veterinary Referral Center or its employees liable for any consequences directly or indirectly related to all services provided. I am fully aware that all charges for services provided are my responsibility. I agree to pay all charges incurred by my pet at the time of his/her release. Failure to communicate with the staff at FVRC for more than 2 days without prior arrangements will be considered abandonment of my pet. Any abandoned animal will be handled by the hospital according to state regulations. Late payments are subject to a late charge of 1.5% each 30 days or less. All collection cost and reasonable attorney’s fees are my responsibility.
Admission Policy
By signing below, I hereby affirm that I am the legal guardian of the above-described pet and am 18 years or older. I fully understand that no guarantee of successful treatment is made and will not hold the Florida Veterinary Referral Center or its employees liable for any consequences directly or indirectly related to all services provided. Failure to communicate with the staff at FVRC for more than 2 days without prior arrangements will be considered abandonment of my pet. Florida Veterinary Referral Center will handle any abandoned animal according to state regulations.
Telephone Updates
Your doctor will give a complete medical and financial update to the designated family member once daily. Additionally, a doctor or veterinary technician will contact you if they have any questions or concerns during your pet’s hospitalization.
Our staff attends medical rounds twice daily and perform daily exams on patients to discuss and determine treatment plans. This is done from 8am-9am and 8pm-9pm. We ask that you please call before or after these hours for updates.
Patient Belongings
We understand the desire to provide your pet with personal comforts of home such as blankets or stuffed toys during their hospitalization. However, we cannot assume responsibility for the loss of or damage to these belongings. We ask that personal belongings such as leashes, collars, carriers, beds, toys, or anything not related to the treatment of your pet, be kept at home.
By signing below, you are acknowledging that you understand our policies and procedures. We thank you for your cooperation and for entrusting us with the care of your pet!
Medical Release Policy
By signing below, I hereby authorize Florida Veterinary Referral Center to release my pet’s medical records to the individuals(s) listed under the Primary Veterinarian(s) and/or Specialists’ Information paperwork.
Client Authorization and Consent to the Payment, Admission, Telephone Update, Patient Belongings, and Medical Release Policies*
Today's Date*
CAPTCHA

Owner Information

Patient Information

Primary Veterinarian Information