CLIENT INFORMATION: NAME ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE ADDRESS

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1 Thank you for giving us the opportunity to care for your pet(s). We will be happy to answer any and all questions you may have about your pet s health. CLIENT INFORMATION: NAME ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE ADDRESS DRIVER S LICENSE NO. DATE OF BIRTH *In case we do prescribe controlled medication, we will need to verify age. EMERGENCY CONTACT NAME PHONE NUMBER RELATION AUTHORIZE TREATMENT FOR YOUR PET(S)? YES NO HOW DID YOU HEAR ABOUT US? I hereby authorize the veterinarian to examine, prescribe and treat my pet(s). I assume responsibility for all charges incurred in the case of my pet(s). I understand that a deposit may be required before treatment and that charges will be paid at the time of release. If my account should become delinquent, I will be responsible for all costs of collections including attorney fees and court costs. CLIENT SIGNATURE DATE We accept; cash, check and credit/debit card (Visa, MasterCard, Discover and American Express). All animals hospitalized or boarding with us must be current on vaccinations. Proof of vaccine history is required.

2 YOUR PET S HEALTH HISTORY Name: Species: Dog Cat Other: Breed: Color: Date of Birth: Sex: Male Neutered Female Spayed Previous Veterinarian: Phone: Canine History (List Dates Done): DHPP/Corona: Bordetella: Rabies: Fecal/Giardia Test: Heartworm Test/Prevention: Feline History (List Dates Done): FVRCP: FELV: FIP: Rabies: FELV/FIV Test: Fecal/Giardia Test: Has your pet had any previous illnesses? Has your pet had any surgeries? Does your pet have any allergies or reactions to any medication/vaccine? Is your pet taking medication? If your pet on a special diet?

3 Arbitration Contract Article 1: Arbitration of Disputes. It is understood that any dispute as to veterinary malpractice, that is as to whether any veterinary services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: Definitions. Client as used in this contract includes the undersigned individual, his or her pet (s), heirs, assigns, and personal representatives. The individual signing this contract signs it on behalf of the foregoing persons, and intends to bind each of them to arbitration to the full extent permitted by law. The Clinic as used in this contract includes Encino Veterinary Clinic, Inc. and Calabasas Veterinary Center, Inc., all veterinary doctors and/or independent contractors who practice veterinary medicine at the Clinic, and any officers, owners, parent companies, employees, subsidiaries, insurers, affiliated entities, agents, successors, and assigns of the foregoing individuals or entities. Article 3: Procedure. Client may initiate arbitration by notifying Doctor of a desire to arbitrate. Notice to Doctor shall be sent by personal delivery or certified mail to Dr. James Isaacs, Encino Veterinary Clinic, Ventura Blvd., Encino, CA the parties will agree on an arbitrator within sixty (60) days. If the parties cannot agree on an arbitrator, they will arbitrate using ADR Services, Inc. to select an arbitrator. The arbitration shall be conducted under the California Arbitration Act. (Cal. Civ. Proc. Code ), and shall also be governed by California Civil Code and and California Code of Civil Procedure and The arbitrator shall have authority to order such other discovery as deemed appropriate for a full and fair hearing of the case. A determination on the merits shall be rendered in accordance with the law of the State of California including the provisions of the Medical Injury Compensation Reform Act of 1975 which shall apply to the same extent as if the dispute were pending before a Superior Court of this State. Any controversy concerning the interpretation or application of the Agreement itself shall also be submitted to arbitration in the manner provided above. Article 4: Severability. If any provision of this contract is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. Article 5: Revocation. Once signed, this contract governs all subsequent open-book accounts and transactions for veterinary services for which the contract was signed until or unless rescinded by written notice within thirty (30) days of signature. Written notice of such rescission may be given by a guardian or conservator if Client is incapacitated or is a minor.

4 If Client signs this contract and Client changes his or her mind about the contract, Client may rescind the contract, and will therefore no longer be bound by its terms, by providing the Clinic with written notice of rescission within thirty (30) days from the date of signing. Written notice should be sent to Dr. James Isaacs, Encino Veterinary Clinic, Ventura Blvd., Encino, CA NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF VETERINARY MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. Client Name: Client Signature: _ Date: Approved on Behalf of Doctor: By: Date:

5 Publicity Release Form In the course of advertising, public relations or other similar conduct for business purposes, Calabasas Veterinary Center may utilize media sources. I grant to Calabasas Veterinary Center, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically without compensation. I agree that Calabasas Veterinary Center may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. This would be true of any written statement I have made regarding my pet or my experiences at Calabasas Veterinary Center. Calabasas Veterinary Center may take photos of me and/or my pet. Calabasas Veterinary Center may NOT take photos of me and/or my pet. Printed Name Date Signature Date Pet s Name: Breed: Color: