Admission FormOwner InformationOwner(s) Full Name*Email Address* Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home PhoneCell PhoneOther PhoneResidential Status*Full-TimeSeasonalVisitorPatient InformationPet's Name*Type of Animal*DogCatOtherBreed*Gender*MaleFemaleSpayed/Neutered?*YesNoAge or DOB* Date Format: MM slash DD slash YYYY Color*DietOn Heartworm Preventative?*YesNoList any current medicationsList any current medical diseases/problemsList any known allergies/reactions to medicineReason for visit today?Primary Veterinarian InformationDoctor's NameHospitalAddress City State / Province / Region PhonePlease note referring doctor (if different from primary doctor)Hospital NameAddress City State / Province / Region Another veterinarian you have seen, please name hereHospital NameAddress City State / Province / Region How did you hear about us? My Veterinarian Community Event/Magnets Mailings Friend/Family Internet / Website Facebook Pet Pages Better Business Bureau Phonebook OtherI 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.