Shaffer Animal Hospital - New Client Form

1
Your Information
First Name
Last Name
Cell Phone
Home Phone (if applicable)
Email
2
Your Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
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Chile
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Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
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Denmark
Djibouti
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Dominican Republic
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Liberia
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Madagascar
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Mali
Malta
Marshall Islands
Martinique
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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
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Russia
Rwanda
Saint Barthelemy
Saint Helena
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Samoa
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Saudi Arabia
Senegal
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eSwatini
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Emergency Contact Information* I hereby authorize the person named as emergency contact to make all medical decisions in the event I am unable to be reached.
Emergency Contact Name
Emergency Contact Phone Number
4
How did you hear about us?
Social Media
Google
Website
Referral
Drive By
Other
5
Who can we thank for your referral?
6
Date of Appointment* This field is required.
Date
Month
Day
Year
7
As a Fear Free Certified Professional team, we want to make you pet’s veterinary experience as enjoyable and as stress free as possible. As such, it’s important for us to understand what your pet might find upsetting. The information will help us to adjust our care to better serve and comfort your pet. Please answer the following questions to the best of your ability so we can take into consideration both your & your pet’s preferences.
8
Pet Information #1
Name
D.O.B
Canine
Feline
Other
Species
If other , Please specify
Breed
Color
Male
Female
Sex
Spayed
Neutered
I don't know
No

Spayed/Neutered
9
Is your pet microchipped?* This field is required.
YESNO
10
What is the number?
11
Does your pet show any reluctance to getting in the carrier or car?
Yes
No
12
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.)
13
During travel to the veterinary hospital, does your pet do any of the following:
Eager & excited
Reluctant
Hide
Drool
Vomit
Urine/BM
Subdued
Bark/Meow
Whine
Pant
Tremble
Pace
14
Does your pet prefer
Female veterinary professional
Male veterinary professional
It doesn't matter
15
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end
Getting in their carrier or the car
Entering the veterinary hospital
Other pets and/or people passing by while in reception/check-in
Waiting with other people and animals in the waiting area
Being approached by veterinary staff
Getting on the scale for a weight
Hearing the doorbell, overhead intercom, or phones ringing
Sounds coming from the back areas of the practice
Going into the exam room
Being put up on the table for examination
Having direct eye contact with the technician and/or veterinarian
Loud voices during examination
Having a rectal temperature taken
The use of instruments such as the stethoscope or otoscope (to look in the ears)
Being taken out of the exam room for procedures
16
How would you describe your pet around other animals and people?
17
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
18
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) If so, how did you pet react?
19
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital):
20
Does your pet like to play with toys? If so what kinds?
21
Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience?
22
Anything else you would like us to know?
23
Add a second pet?* This field is required.
YESNO
24
Pet Information #2* This field is required.
Name
D.O.B
Canine
Feline
Other
Species
If other , Please specify
Breed
Color
Male
Female
Sex
Spayed
Neutered
I don't know
No

Spayed/Neutered
25
Is your pet microchipped?* This field is required.
YESNO
26
What is the number?
27
Does your pet show any reluctance to getting in the carrier or car?
Yes
No
28
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.):
29
During travel to the veterinary hospital, does your pet do any of the following:
Eager & excited
Reluctant
Hide
Drool
Vomit
Urine/BM
Subdued
Bark/Meow
Whine
Pant
Tremble
Pace
30
Does your pet prefer
Female veterinary professional
Male veterinary professional
It doesn't matter
31
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end
Getting in their carrier or the car
Entering the veterinary hospital
Other pets and/or people passing by while in reception/check-in
Waiting with other people and animals in the waiting area
Being approached by veterinary staff
Getting on the scale for a weight
Hearing the doorbell, overhead intercom, or phones ringing
Sounds coming from the back areas of the practice
Going into the exam room
Being put up on the table for examination
Having direct eye contact with the technician and/or veterinarian
Loud voices during examination
Having a rectal temperature taken
The use of instruments such as the stethoscope or otoscope (to look in the ears)
Being taken out of the exam room for procedures
32
How would you describe your pet around other animals and people?
33
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
34
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) If so, how did you pet react?
35
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital):
36
Does your pet like to play with toys? If so what kinds?
37
Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience?
38
Anything else you would like us to know?
39
Add a third pet?
YESNO
40
Pet Information #3* This field is required.
Name
D.O.B
Canine
Feline
Other
Species
If other , Please specify
Breed
Color
Male
Female
Sex
Spayed
Neutered
I don't know
No

Spayed/Neutered
41
Is your pet microchipped?* This field is required.
YESNO
42
What is the number?
43
Does your pet show any reluctance to getting in the carrier or car?
Yes
No
44
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.):
45
During travel to the veterinary hospital, does your pet do any of the following:
Eager & excited
Reluctant
Hide
Drool
Vomit
Urine/BM
Subdued
Bark/Meow
Whine
Pant
Tremble
Pace
46
Does your pet prefer
Female veterinary professional
Male veterinary professional
It doesn't matter
47
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end
Getting in their carrier or the car
Entering the veterinary hospital
Other pets and/or people passing by while in reception/check-in
Waiting with other people and animals in the waiting area
Being approached by veterinary staff
Getting on the scale for a weight
Hearing the doorbell, overhead intercom, or phones ringing
Sounds coming from the back areas of the practice
Going into the exam room
Being put up on the table for examination
Having direct eye contact with the technician and/or veterinarian
Loud voices during examination
Having a rectal temperature taken
The use of instruments such as the stethoscope or otoscope (to look in the ears)
Being taken out of the exam room for procedures
48
How would you describe your pet around other animals and people?
49
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
50
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) If so, how did you pet react?
51
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital)
52
Does your pet like to play with toys? If so what kinds?
53
Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience?
54
Anything else you would like us to know?
55
Add a fourth pet?
YESNO
56
Pet Information #4* This field is required.
Name
D.O.B
Canine
Feline
Other
Species
If other , Please specify
Breed
Color
Male
Female
Sex
Spayed
Neutered
I don't know
No

Spayed/Neutered
57
Is your pet microchipped?* This field is required.
YESNO
58
What is the number?
59
Does your pet show any reluctance to getting in the carrier or car?
Yes
No
60
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.)
61
During travel to the veterinary hospital, does your pet do any of the following:
Eager & excited
Reluctant
Hide
Drool
Vomit
Urine/BM
Subdued
Bark/Meow
Whine
Pant
Tremble
Pace
62
Does your pet prefer
Female veterinary professional
Male veterinary professional
It doesn't matter
63
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end
Getting in their carrier or the car
Entering the veterinary hospital
Other pets and/or people passing by while in reception/check-in
Waiting with other people and animals in the waiting area
Being approached by veterinary staff
Getting on the scale for a weight
Hearing the doorbell, overhead intercom, or phones ringing
Sounds coming from the back areas of the practice
Going into the exam room
Being put up on the table for examination
Having direct eye contact with the technician and/or veterinarian
Loud voices during examination
Having a rectal temperature taken
The use of instruments such as the stethoscope or otoscope (to look in the ears)
Being taken out of the exam room for procedures
64
How would you describe your pet around other animals and people?
65
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
66
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) If so, how did you pet react?
67
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital):
68
Does your pet like to play with toys? If so what kinds?
69
Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience?
70
Anything else you would like us to know?
71
May we request records from your previous veterinarian? * This field is required.
YESNO
72
What is the hospital name?
Hospital Phone number
73
Upload previous medical records
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
74
May we take your pet(s)’ photo?* This field is required.This will be used for their medical record and may also be used for social media
YESNO
75
TERMS OF SERVICE:

We accept cash, check, Visa, MasterCard, Discover, American Express, and Care Credit as forms of payment.

On your request, we will provide you with a written estimate of fees for any treatment or services we provide. Please note: these estimates are individually tailored and subject to
change based on your pet(s)’ health. Every effort will be made to notify you of any updates as they arise if your pet is receiving ongoing treatment.

I understand that FULL PAYMENT IS DUE AT THE TIME SERVICE IS RENDERED and that a DEPOSIT IS REQUIRED FOR ANY HOSPITALIZED PET. All unpaid balances are subject to a 1.5% per month interest charge. Returned checks are subject to the incurred returned check fee. In the event legal action is required to recover an unpaid balance, I agree to pay all interest, court costs and attorney’s fees.

All information I have provided here is true to the best of my knowledge. I have read and understand the Terms of Service.
76
Please print your name* This field is required.
77
Signature* This field is required.Use your mouse or finger to sign your name below.
Clear
78
Date * This field is required.
Date
Month
Day
Year
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