Legacy Animal Hospital

Phone: (623) 505-3100

Mon-Fri: 8:00am-6:00pm

Serving: Goodyear, AZ & Surrounding Communities
We Accept Most Major Credit Cards
Credit Cards

Purina Pro Plan

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New Client Registration

"*" indicates required fields

Step 1 of 2

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Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following form.       If you try to submit the form and find that it does not work, please be sure that ALL required* areas are complete. Thank you!
Address*

All Fees Are Due At the Time Services Are Rendered

How did you become aware of our clinic?
Pet Information
Name
Breed
Date of Birth
Color
Microchip#
Sex
Spayed or Neutered
YOUR DOG’S VACCINATION HISTORY:
RABIES
LEPTOSPIROSIS
DAP PARVO
BORDETELLA
FECAL (STOOL SAMPLE)
HEARTWORM TEST/PREVENTION
 
YOUR CAT’S VACCINATION HISTORY:
RABIES
FELV
FVRCP
LEUKEMIA/FIV TEST
FECAL (STOOL SAMPLE)
 
Our pet(s) is:
Consent: You will be asked to sign a health plan confirming authorization of treatment after a tentative diagnosis. The details of treatment, the risks of treatment, and/or the risk of not treating will be explained to you.
May we post a picture of your pet on social media or display it in our lobby?

Authorization

By signing this form, you certify that you are the owner of the animals listed above. I hereby authorize services to be provided for my pet as required for maintaining proper health. I also understand that all fees are and payable when services are rendered, and that I am responsible for any charges incurred due to returned checks or through collection efforts. I authorize the above mentioned hospital/clinic to send all records or recorded statements on my behalf.
MM slash DD slash YYYY
If you try to submit the form and find that it does not work, please be sure that ALL required* areas are complete. Thank you!

No-shows, late shows, and cancellations inconvenience those individuals who need access to veterinary care. Please read our cancellation policy on the tab above. Thank you.

Legacy Animal Hospital

Waiver of Responsibility and Liability for Prescriptions and Products Filled By Outside Internet
Pharmacies or Catalog Vendors No Associated with This Hospital
Client's Name*

I Hereby request a prescription for medication(s) for my pet so that I can purchase these products from an outside internet pharmacy or catalog vendor not associated with this clinic. By signing this waiver, I acknowledge that I have been properly informed of the risks involved in doing so, and accept any and all responsibility, financial or otherwise, that may occur from this decision. I understand that Legacy Animal Hospital and its associated staff will be held harmless from the use of products and/or prescriptions purchased from sources outside of the hospital’s monitoring and control.

Risks Involved in Purchasing Pharmaceuticals or Other Products for My Pet From Internet Pharmacies or Catalog
Vendors May Include and Are not Limited To:

There is no way for my veterinarian to know if the product has been stored properly when in transit, is out of date, repackaged or counterfeit when purchased from outside internet source. This is a valid concern as it has occurred in the past and is likely to recur at any time. For more information on this topic, visit the FDA website at www.fda.gov and enter Internet Pharmacies in the FDA search bar.

The prescribing instructions for product purchase from other sources may be different from those recommended by my veterinarian. This could result in improper dosing of my pet.

Purchases from outside on-line pharmacies may not appear in my pet’s medical records provide by my veterinarian. This information may be important in the event that my pet needs additional medications and/or treatment from my veterinarian.

Product warranties for prescriptions obtained from outside internet pharmacies may be different than the manufacture’s normal warranties or potentially unavailable. It is understood that my veterinarian is unable to offer warranties for products of prescriptions obtained through outside sources.

The prescription and/or its refills may not arrive in a timely fashion, thus potentially causing an interruption in treatment for my pet, which may result in the need for additional testing prior to the continued safe use of the product.

Manufactured rebates that would ordinarily be available for products purchased from this facility will not be honored when purchased from online pharmacies or catalog vendors.

Vaccines purchased through internet pharmacies or catalog vendors may not be accepted as valid by kennels, airlines, licensing agencies or veterinary practices.

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Legacy Animal Hospital

Phone: (623) 505-3100 Address: Goodyear, AZ & Surrounding Communities

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