Owner Name*

First Last

Co-Owner's Name

First Last

Address*

Apt. #

City*

State*

ZIP code*

Cell Phone*

Alternative Phone

Email Address*

Pet's Name*

Species*

Breed*

Color*

Date of Birth (mm/dd/yyyy)*

Sex*

Female intact

Female spayed

Male intact

Male neutered

Does your pet have a history of fear, anxiety, aggression or biting?*

If yes, please describe.

Primary Care Hospital*

Primary Care Veterinarian*

Additional Veterinarians

Specialty*

Diagnostic Imaging

Internal Medicine

Neurology

Oncology

Ophthalmology

Surgery

Options will be dynamically rendered based on the hospital.

Reason for Visit Details*

Please list any health problems and current medications*

Please list any pet health insurance you have

Where we deem necessary, our default is to take life-saving measures to stabilize your pet, which may include resuscitation. You may choose to update your preference for emergency medical directive during consultation with our medical team.

Consent to Treat

I, the undersigned, do hereby certify that I am over the age of 18 and am the owner (or authorized agent) of the above-described patient. I authorize BluePearl Specialty and Emergency Pet Hospital (and its affiliates, employees, agents and contractors) to receive, examine, prescribe for and treat the above-described pet. I further understand that no guarantee of successful treatment is made and I will not hold BluePearl Specialty and Emergency Pet Hospital (or its affiliates, employees, agents or contractors) responsible for my pet’s recovery.

Payment Policy

A deposit will be required prior to treatment and/or hospitalization. Full payment for services rendered is required prior to discharge of your pet from the hospital. I am aware that all diagnostics, treatment and medication charges are in addition to any examination fee and agree to pay all charges incurred at the time of service. In the event of a check returned NSF or stop payment, a $25 fee will be added to the account. Late payments are subject to a late charge of 1.5% each 30 days or less. Any collection costs including reasonable attorney’s fees will be borne by me, the customer.

Records and Communication Policy

BluePearl Specialty and Emergency Pet Hospital is part of your pet’s continuum of care, and we may provide your family veterinarian, any specialists, and/or a reviewing body information regarding your pet’s treatment and/or condition. By signing below, you are authorizing BluePearl Specialty and Emergency Pet Hospital to share your pet’s medical record with a third party (such as your family veterinarian) or its agent necessary for us to provide continuous veterinary care to your pet. You agree that we (or our agents) may send you communications to your contact information provided above regarding your pet.

Client Signature*

Date*

Data Privacy Notice

BluePearl Specialty and Emergency Pet Hospital and our affiliated entities are committed to providing quality and informed services to and for you and your pet. We aim to be your partner in your pet’s long-term health and happiness through a variety of means, including by considering clinical studies, diagnosis and analysis from across our veterinary hospitals and brands. As part of this mission, we work with our affiliates, parent and subsidiaries to provide the services you request and to analyze and evaluate the patterns of diagnosis and treatment of the pets treated at our facilities. From time to time we, BluePearl Specialty and Emergency Pet Hospital, and our affiliates, may also use the data collected from you and your pet for advertising and promotion of goods and services that may be of interest and beneficial to you and your pet. In addition, we may use such data and/or any residual biological samples collected from your pet for clinical studies to advance veterinary knowledge. Please visit our privacy policy for more information about the collection and use of your data and how to opt out of some forms of sharing.

Data Privacy Notice for California

BluePearl Specialty and Emergency Pet Hospital and our affiliated entities are committed to providing quality and informed services to and for you and your pet. We aim to be your partner in your pet’s long-term health and happiness through a variety of means, including by considering clinical studies, diagnosis and analysis from across our veterinary hospitals and brands. As part of this mission, we work with our affiliates, parent and subsidiaries to provide the services you request and to analyze and evaluate the patterns of diagnosis and treatment of the pets treated at our facilities. From time to time we, BluePearl Specialty and Emergency Pet Hospital, and our affiliates, may also use the data collected from you and your pet for advertising and promotion of goods and services that may be of interest and beneficial to you and your pet, and we may use such data and/or any residual biological samples collected from your pet for clinical studies to advance veterinary knowledge. Please visit our privacy policy for more information about the collection and use of your data. You may have the right to request deletion of your personal information, access to our information, to opt-out of certain sharing of your personal information, and more. To do so, please contact us at 1-855-900-8444, or c/o Data Analytics, 2950 Busch Lake Blvd., Tampa, Florida 33614. Please note that, notwithstanding your request, we may still retain certain categories of personal information for numerous purposes, including without limitation, to comply with certain legal obligations, such as record retention requirements.

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Current Hospital

Current hospital will be selected by default.

BluePearl Pet Hospital
Grand Rapids, MI

Specialty Appointment Request Form

Consent to Treat

Payment Policy

Records and Communication Policy

Data Privacy Notice

Data Privacy Notice for California

BluePearl Pet Hospital Grand Rapids, MI

Specialty Appointment Request Form

Consent to Treat

Payment Policy

Records and Communication Policy

Data Privacy Notice

Data Privacy Notice for California

BluePearl Pet Hospital
Grand Rapids, MI