Arcata Animal Hosital

Arcata Animal Hosital

Thank you for choosing Arcata Animal Hospital
CLIENT INFORMATION
Primary owner name (must be 18+)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone

Area CodePhone Number
Additional Phone

Area CodePhone Number
E-mail
What is your preferred method of contact?

PhoneEmailText Message
Employer
Work Phone

Area CodePhone Number
May we contact you at work?

yesno

Additional Owner/Agent Name
Authorized to make medical decisions?

YesNo
Primary Phone #

Area CodePhone Number
E-mail
Employer
Work Phone

Area CodePhone Number
May we contact you at work?

YesNo
In addition to the persons listed above, the following people have the authority to make medical decisions for all pets llisted on my file, up to and including spaying, neutering, and euthanasia.
1
2
Are you eligible for our senior discount on exam fees (60 years & up)?

YesNo

Rabies Certificates
I understand that in accordance with Humboldt County Ordinance Code Section 542-5, Arcata Animal Hospital provides a duplicate copy of canine rabies certificates to the Humboldt County Animal Control.
Initials
After Hours Personnel
I understand that veterinary service during nighttime hours, some daytime hours, and/or weekends, is provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not be provided during these hours. ( California Code of Regulations: Title 16 Section 2030)
Initials
Release of Liability
I understand Arcata Animal Hospital will use all reasonable precautions for the safekeeping of hospitalized animals, but the hospital will not be held responsible in any manner whatsoever on account of medical situations that may arise (such as self-injury or escape), as it is understood that I assume all risks.
Initials
Social Media
We love social media! Do we have your permission to share your pet(s) image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared.
YesNo
Use of "Extra-Label" Pharmaceuticals
The Food and Drug Administration (FDA) oversees the licensing of pharmaceuticals for humans and animals. Many drugs that have been approved for use in humans and/or some animals have also been proven to be safe and effective in species for which the drugs are not labeled. "Extra-label use" is defined as:
"Actual use or intended use of a drug in an animal in a manner that is not in accordance with the approved labeling. This includes, but is not limited to, use in species not listed in the labeling, use for indications (disease and other conditions) not listed in the labeling, use at dosage levels, frequencies, or routes of administration oter than those stated in the labelling, and deviation from labeled withdrawal time based on these different uses." (21 CFR 530.3(a))

Extra-label use does not include the use of experimental drugs or drugs manufactured in foreign countries that have not been approved by the FDA.

All drugs can potentially cause harmful side effects, including death. The drugs that will be used for your pet at Arcata Animal Hospital have been safely used in individuals of the same or related species. When a drug must be used to treat an unusual disease or an unusual species, effectiveness and safety can be difficult to predict. You will be advised when your pet has been prescribed a medication that has not been given to a significant number of individuals of a similar species with a similar medical condition.

I have read and understand the above policy on the use of extra-label pharmaceuticals. I authorize the staff at Arcata Animal Hospital to administer and prescribe extra-label drugs for my pet. I understand that any drug, including those that are used in an extra-label manner, can produce undesirable side effects. Thus, I acknowledge that it is my responsibilty to administer prescribed medications for my pet as directed and to notify my veterinarian of any apparent side effects or complications.
Signature
Date
Should be Empty: