New Client/Patient: Pre-Visit Form

New Client/Patient: Pre-Visit Form

We are so excited to see you and your pet for your upcoming visit! Prior to your pet's appointment we ask that you take the time to provide your contact information andanswer the following questions regarding your pet's medical history and currentlifestyle.
Part 1: Client Information
Client Name*

First NameLast Name
Primary Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
Secondary Client Name

First NameLast Name
Secondary Phone Number

Area CodePhone Number
If this is your first visit, how did you hear about All Pets Health Center?

Part 3: Medical Assessment
Reason for Visit:*
What is your pet's current diet? How much are your feeding?*
Does your pet get treats or snacks? If so, what type or brand? Can your pet have treats/peanut butter during their visit today?*
Has your pet been previously diagnosed with any health conditions?*
Is your pet currently taking any medications, supplements or monthly preventative? If so, please list.*
Do you have any other pet's in the house? If so, please list.*
Do you take your pet to any of the following(check all that apply)?*

ParksPet Daycare facilityBoarding or grooming facilityObedience TrainingHiking/CampingNone of the above
What kind of exercise does your pet get? *
Has your pet been seen at another clinic in the past? If so, please provide the name and phone number so we may acquire any previous medical records. *
Alternatively, you can upload previous medical records here.

Browse Files

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Part 5: Consent to Release Information
I give consent for All Pets Health Center to release/receive information for all of my pets to the following:*

Boarding/Grooming FacilitiesAny Veterinary Clinics and/or HospitalsBreeders and/or Rescue organizationsPet Insurance companiesNone of the aboveOther
I grant permission to All Pets Health Center to use images or videos taken of my pet(s) for use in digital or printed materials for any lawful purposes that may include advertising, display distribution, marketing materials, website content, and social media.*

YesNo
I authorize the following individuals, not already listed on my account, to act as an agent for my pet's medical care in the event that I am not present.
By signing below, I certify that I am above the age of eighteen and am the person listed above.
Signature

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Part 1: Client Information