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Client-Patient Registration Form

Thank you for giving us the opportunity to care for your pet. To ensure your pet gets the best care
possible, please take some time to fill out this form so we may better get to know you.

Date

Owners Name

Spouse/Co-Owners Name

Relation to owner

Address

City/State/Zip Code

Home Phone or Cell # (circle one)

Co-Owner Cell

E Mail

How Did You Hear About Our Hospital?(List Specific Source)

Who Is Your Regular Attending Veterinarian/Hospital?

Pets Name

Species/Breed

Date Of Birth

Gender

Neutered/Spayed

Color/Markings

Extra Pet Details need to be added

Yes

Pets Name

Species/Breed

Date Of Birth

Gender

Neutered/Spayed

Color/Markings

Check if you are 18 years or older.

Yes

Does your pet have any significant past medical or behavioral issues

Yes

If yes, please describe

As a general reminder, our general exam fee is $89 per pet, $133 for emergency/Walk-Ins. Anything
done beyond that exam will accrue additional fees. All payments are due at time of services rendered.

I hereby authorize the veterinarian(s) to examine, prescribe for, medically treat, and perform surgery on
the above described pet(s). I assume responsibility for all charges incurred in the care of the said
animal(s), and am aware that payment is due upon time of services rendered. I understand that I may be
asked to pay a deposit fee at any time prior to treatment.

PHOTO USE RELEASE FORM

owner of

hereby grant and authorize Advanced
Animal Hospital the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and
all pictures or video taken of me or my pet by Advanced Animal Hospital to be used in and/or for legally
promotional materials including, but not limited to, newsletters, flyers, posters, brochures,
advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites,
social networking sites and other print and digital communications, without payment or any other
consideration. This authorization extends to all languages, media, formats and markets now known or
hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said
authorization in writing.

I understand and agree that these materials shall become the property of Advanced Animal Hospital and
will not be returned.

I hereby old harmless, and release Advanced Animal Hospital from all liability, petitions, and causes of
action which I, mt heirs, representative, executors, administrators, or any other persons may make while
acting on my behalf or on behalf of my pet/estate.

Name of Owner

Name of Pet

ACKNOWLEDGEMENT AND CONSENT FORM

As part of our commitment to providing the best possible care for our customers and their pets,
Advanced Animal Hospital and any of its affiliated hospitals (collectively the
“Hospital”) may, with your consent, use an automated notetaking technology application
utilizing artificial intelligence (the “Application”) to record and transcribe notes from
conversations during veterinary appointments. This AI-powered scribe system assists our
veterinary team by recording and transcribing veterinary consultations to enhance the accuracy
and efficiency of your pet’s medical records. The veterinarian will then review, edit, and
finalize the medical records to ensure all adequate and accurate information is recorded and
maintained.

Our use of the Application for veterinary appointments is purely optional, and we will record
notes of the appointment by traditional means if you do not wish to consent to the recording
and transcription of your voice. This policy explains how the Hospital collects, stores, uses,
and destroys any voice recordings and/or transcripts, which may constitute biometric
information in some jurisdictions, in compliance with applicable laws.

Collection and Usage of Personal Information

We may employ different vendors, such as Scribenote (provided by Scribenote, Inc.) or other
similar vendors (the “System Vendor”) to provide the Application used to record and transcribe
conversations between our veterinary staff and customers, with both parties’ consent, while
fulfilling our customers’ pet care needs.

We do not use or disclose any information outside of what is necessary to transcribe notes
relating to providing pet care, perform quality control review related to the treatment, and assert
or defend claims related to providing our services. The Hospital and its System Vendor will
not sell, lease, trade or otherwise profit from your information.

Retention and Destruction of Your Information

The transcript and recordings of veterinary visits are housed on third-party cloud servers that
are maintained and secured by the System Vendor, and accessible by the Hospital. The Hospital
and its System Vendors treat your information as confidential and exercise reasonable care to
protect it from disclosure to unauthorized third parties. Your information will be destroyed by
the Hospital and its System Vendor when the initial purpose for collecting or obtaining it has
been satisfied or within one (1) year after the records are no longer needed for the pet’s
treatment, unless required to be maintained for longer in accordance with applicable law or as
necessary to defend against claims or assert the Hospital’s rights.

ACKNOWLEDGMENT AND CONSENT:

By signing below, I acknowledge that I have
read the Hospital’s Acknowledgment and Consent, understand it, agree to abide by it and
voluntarily consent to the Hospital’s and/or its System Vendor’s recording, storage, use,
transcription, disclosure, and destruction in accordance with the purposes described above.

Name

Signature

Date

Hospital Representative

Client Account number