Client Registration Forms

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Owner/Caregiver information

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Contact Phone Number - We will call this number with updates, etc. *

We will not discuss any patient or account information with anyone not in our system.

Please add any additional contacts that you authorize Resurge Veterinary Surgical Specialists and Rehabilitation LLC to communicate with regarding your pet or account.

Secondary Contact *

Secondary Phone Number *

Email *

Preferred form of communication *

Referring Veterinarian Name/ Hospital *

Referring Veterinarian Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Patient information

Pet's Name *

Breed *

Gender *

Age *

Date of birth *

Current problem with your pet *

Current Medications *

Known Allergies or Reactions to Drugs *

Duration of problem *

Your First Appointment *

Additional Comments about your pets condition *

Authorization Release

Resurge Veterinary Surgical Specialists and Rehabilitation LLC may use information from patients for purposes such as education and marketing materials. Examples: Continuing education and / or social media.

Choose One *

I DO authorize I do NOT authorize

use of my pet's first name, photograph and clinical information on the Resurge website, social media, or within informational pamphlets. Under no circumstances will my name, my personal or financial information be shared through these media sources.

Resurge Veterinary Surgical Specialists and Rehabilitation LLC may, at the owner's discretion, may take photos and/or videos, when feasible, for sharing with the authorized primary and secondary contacts and independent of social media and continuing education purposes.

Choose One *

I DO Authorize I do NOT Authorize

Resurge Veterinary Surgical Specialists and Rehabilitation LLC., to take photos and/or video of my patient for sharing with the primary and secondary contacts on my account.

Submit

Owner/Caregiver information

Patient information

Authorization Release

Home
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About
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Blog
Client Registration Form
Veterinary Referral information

Contact Us
phone: 985-888-1059
email: [email protected]

Location
641 River Highlands Blvd. Covington, LA 70433.

Owner/Caregiver information

Patient information

Authorization Release

HomeServicesAboutContactBlogClient Registration Form​Veterinary Referral information

Contact Usphone: 985-888-1059email: [email protected]

Location641 River Highlands Blvd. Covington, LA 70433.

Home
Services
About
Contact
Blog
Client Registration Form
Veterinary Referral information

Contact Us
phone: 985-888-1059
email: [email protected]

Location
641 River Highlands Blvd. Covington, LA 70433.