Johnson County - New Patient

1
Client/Patient InformationThank you for giving us the opportunity to care for your pet. So that we may become better acquainted, please complete the following
Pet or Pet’s Name
Identifying marks/colors
2
Owner 1* This field is required.
Mr.
Mr.
Mrs.
Ms.
Dr.
Prefix
First Name
Middle Name
Last Name
3
Owner 2
Mr.
Mr.
Mrs.
Ms.
Dr.
Prefix
First Name
Middle Name
Last Name
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Email Address* This field is required.(in-house use only)
example@example.com
6
Owner # 1 Phone
Home
Work
Mobile
7
Owner # 2 Phone
Home
Work
Mobile
8
Place of Employment (Owner1)
Employer
City
State
9
Place of Employment (Owner1)
Employer
City
State
10
What is the best place and time to reach you?
E-mail
Cell Phone
Home Phone
Work Phone
Preferred method of contact?
Email
Voice
Text
How would you like to be contacted for appointment reminders or upcoming services your pet will be due for?
11
How did you become aware of our hospital
AAHA
Our Website
Hospital Sign
Care Credit
Personal Recommendation
Great Plains SPCA
Facebook
12
If personal recommendation, whom may we thank
Have you been to a veterinary clinic or hospital before?
What was your reason for leaving that practice?
13
Are there any special issues or instructions you would like us to be aware of as we care for your pet?
14
What health care and / or grooming products are you currently using?
Do we have permission to post pictures of your pet(s) on our clinic social media pages or website?
15
We will provide you with a written estimate of fees in advance, if in-hospital treatment, surgery or hospitalization is needed. Except for life-threatening emergencies, all procedures and surgeries will require a 50% deposit prior to treatment. Please be aware that all fees are due prior to the release of your pet.
16
Please provide information for each of the pets you bring to our clinic/hospital
Pet 1
Pet 2
Pet 3
Pet’s Name
Species (Dog, Cat, etc.)
Breed
Color or description
Birth date (approx.)
Sex
Neuter/Spayed ?
DA2P/Parvo vac (last given)
Bordetella vac (last given)
FVRCP vac (last given)
Leukemia vac (last given)
Rabies vac (last given)
Heartworm test
Fecal check (worms)
Feleuk test (cat)
Any dental problems?
Allergies? (including drug)
Current medications and/or special diet
Behavioral problems?
Pet’s Name
Species (Dog, Cat, etc.)
Breed
Color or description
Birth date (approx.)
Sex
Neuter/Spayed ?
DA2P/Parvo vac (last given)
Bordetella vac (last given)
FVRCP vac (last given)
Leukemia vac (last given)
Rabies vac (last given)
Heartworm test
Fecal check (worms)
Feleuk test (cat)
Any dental problems?
Allergies? (including drug)
Current medications and/or special diet
Behavioral problems?
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
Pet 1
Pet 2
Pet 3
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