Forms for Carmel Veterinary Clinic

New Client

If you’re new to our veterinary hospital or we’ve never seen your pet before, please fill out and submit our new client form below.

Location

Information About You

Name

First Name

Last Name

Spouse

Address

City

State/Province

Zip/Postal

Primary Phone

Secondary Phone

Other Phone

Email (for appointment reminders)

Emergency Contact

First Name

Last Name

Phone

Employer

Occupation

How Did You First Hear of Us?

If you are human, leave this field blank.

Prescription Refill

Does your pet need a refill on their prescription? Complete your request here.

Please fill in this form as completely as possible. Please allow at least 24 hours for refill request to be processed. We will contact you if there are any problems with your request.

Please also note that this form is for refills of medications dispensed by our offices. Requests for medications dispensed by outside pharmacies may be submitted by emailing us on the “Contact Us” page or by phoning one of our offices.

Pickup Location

Pickup Date

Name

First Name

Last Name

Email

Phone

Do you prefer to be called or texted?

Called

Texted

Patient (Pet) Name

Species

Canine

Feline

Pet’s Sex

Male

Female

Prescription Drug Name:

Strength

Quantity (if known):

How are You Giving the Medicine? (i.e., once daily, etc.)

Doctor Dispensing

Additional Comments/Questions

Captcha

If you are human, leave this field blank.

Records Release

Release of Medical Records

Use this form to provide written authorization to our veterinarians to release your pet’s medical records.

Location

Name

First Name

Last Name

Address

City

State/Province

Zip/Postal

Phone

Email

In accordance with Indiana State Law, pet medical records may not be disclosed without the client's written consent to "any person other than the client or other veterinarians involved in the care or treatment of the animal".

This document serves as my authorization for a veterinarian (or his/her designee) at Fishers Veterinary Associates to release the medical history of any of my pets as deemed necessary at the time of the request including medications and/or treatments past and present.

This document shall be placed in my file and is in effect immediately upon receipt by that facility and/or the date below, and shall remain in effect until written
instructions direct otherwise.

By signing this agreement, I authorize Fishers Veterinary Associates to provide a copy, summary, or narrative of my pet's medical records or to otherwise release confidential information for all pets on my account.

Signature

Clear

Date

Captcha

If you are human, leave this field blank.

Online Forms