Admission Form

  • Owner Information

  • Patient Information

  • Primary Veterinarian Information

  • 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.

    •EMERGENCY EXAM FEE: $100.00

    •STANDARD SPECIALTY CONSULT FEE: $125.24

    •After-hours, Stat Critical Care, or Extended Specialty Consultation Fee’s range up to $300.00

    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.

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Request Medication Refill

  • Once your request has been submitted you will be contacted within 24 hours. (Monday-Friday)
    If you are submitting this form on a weekend (Sat-Sun) your prescription will not be filled until the following Monday. If you need your refill sooner please call our hospital and we will be happy to assist you.
    Note: Florida Pharmacy Law requires that all pets have a current doctor patient relationship. Please feel free to contact us with questions.
  • Medication Details

  • (Ex: 1/2 tablet twice a day.)
  • (Ex: 30 tablets or 1 month supply etc.)
  • (If not at FVRC, please list the name of the pharmacy, location and phone number.)

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Client Survey

  • In order to provide you and your pet with exceptional service and care, the doctors and staff of Florida Veterinary Referral Center would like to hear from you. Please tell us how we are doing by completing this form. Thank you for allowing us to serve you!
  • Date Format: MM slash DD slash YYYY
  • Drop files here or
    Accepted file types: jpg, png, jpeg.

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Doctor Survey

  • In an effort to provide you and your clients with exceptional service and attention, the doctors and staff of Florida Veterinary Referral Center would appreciate your input. Please tell us how we are doing by completing this survey and submitting it.

    Thank you for allowing us to serve you with your patient's needs.