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

  • Patient Information

  • Primary Veterinarian Information

  • I hereby affirm that I am the legal guardian of the above-described pet. 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.

    I also hereby authorize Florida Veterinary Referral Center to release my pet’s medical records to myself and to my primary veterinarian(s).

    By submitting this form, you are agreeing to Florida Veterinary Referral Center's terms and conditions listed above.