NEW CLIENT INFORMATION

NEW CLIENT INFORMATION
Thank you for choosing CHAI for your pet’s health care needs. We look forward to serving you and caring
for your pet for many years to come. To open an account with us, you must be at least 18 years of age.
Your Name:
Home Phone:
Cell Phone:
Email Address:
example@example.com
Address:
City:
State:
Zip:
Preferred Method of Contact? (Home, Cell, Email)
CHAI will routinely email lab results and instructions to you at the address provided above. Please ensure that the email address is legible and complete. If you change your home address, your email address, or telephone number, please update us as soon as possible to ensure continued communications.
Employer:
Employer Phone:
Alternate Contact:
Alternate Phone:
How did you hear about CHAI?
Regular Vet
Would you like us to notify your regular vet about the treatment plan we have prescribed for your pet?

YesNo
Regular Vet Contact Number (If Yes to previous question)
May we use a photo/video of your animal (no names will be used) on our social media?

YesNo
We pledge to do our very best to care for your pet’s health care needs. In return we ask that you accept responsibility for charges incurred in the treatment of your pet and accept that payment is due when services are rendered. Please feel free to ask for an estimate of the treatment plan prior to receiving services.
Agreement Terms: A fee of $30 will be charged for all checks returned unpaid. Additional fees will be charged if your account is turned over to collections.
If appointment is booked, a 24 hour cancellation notice is required to avoid a no show fee of $68.00
By signing below, you agree that you are the owner of the patient you have presented to CHAI for treatment and that you will personally assume responsibility for all charges incurred.
Client Signature (Use your mouse or finger to sign):

Clear
Date:

MonthDayYear
Date
Client Name:
PET INFORMATION
Pet 1: Name:
Age or Birthday:
Species:
Breed:
Color:
Markings:
Gender

MaleFemale
Is your pet Spayed/Neutered?

YesNo
Is your pet known to bite?

YesNo
Known Medical Conditions:
Current Medications:
Has your pet ever had a reaction to vaccines, foods, medications or anesthesia?

YesNo
If yes, describe the reaction
Other Noteworthy Information About Your Pet:
Pet 2: Name:
Age or Birthday:
Species:
Breed:
Color:
Markings:
Gender

MaleFemale
Is your pet Spayed/Neutered?

YesNo
Is your pet known to bite?

YesNo
Known Medical Conditions:
Current Medications:
Has your pet ever had a reaction to vaccines, foods, medications or anesthesia?

YesNo
If yes, describe the reaction
Other Noteworthy Information About Your Pet:
Pet 3: Name:
Age or Birthday:
Species:
Breed:
Color:
Markings
Gender

MaleFemale
Is your pet Spayed/Neutered?

YesNo
Is your pet known to bite?

YesNo
Known Medical Conditions:
Current Medications:
Has your pet ever had a reaction to vaccines, foods, medications or anesthesia?

YesNo
If yes, describe the reaction
Other Noteworthy Information About Your Pet:
DETAILED PET INFORMATION
Pet’s Name:
Today’s Date:

MonthDayYear
Date
What is the reason for your visit today? What symptom that your pet is having are you most concerned about?

0/15
When did you first notice the symptom or issue?

0/15
Please list any other current issues:

0/15
Please list any previous, major health concerns:
Please describe your pet’s diet in detail:

0/15
Please pick one of these five descriptions that best describes your pet’s personality:

Easy going, loves everyone, laid back, easily satisfied, patient, social, slow reaction to strangers.Fearful, quiet, independent, one person pet, shy, smart, runs away from strangers.Well-behaved, obedient, likes a routine, problem solver, ignores strangers.Dominant, very active, moves fast, competitive, stubborn, gets mad when he/she doesn’t get their way, barks at strangers.Excitable, hard to calm down, likes to be center of attention, mischievous, wags tail for strangers.
Please check all boxes below that describes your pet:

Decreased appetiteBack painIncreased appetiteLimpingPet prefers to sleep in warm/sunny locationsVomitingWeight lossPet prefers to sleep in cool/shady locationsDiarrheaCoughingConstipationSneezingPainfulIncreased thirstVision problemsDecreased thirstHearing problemsPants when restingLumps on bodyFatigue/lethargyRestless, doesn’t sleep at nightUrinary incontinenceBad breathItchy skinDry skinBleeding at any location, or blood in stool or urineSmelly ears or dischargeGreasy/smelly skinBehavioral problems
If Painful was checked above, where?
Should be Empty:

NEW CLIENT INFORMATION

PET INFORMATION

DETAILED PET INFORMATION