Shaffer Animal Hospital - New Client Form

1
Have you already scheduled your pet's appointment?* This field is required.
Yes
No
2
Please call our office (407) 366-1722 to schedule an appointment prior to completing this form.
3
Your Information* This field is required.
First Name
Last Name
Cell Phone
Home Phone (if applicable)
Email
4
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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Algeria
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Central African Republic
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Chile
China
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Cocos (Keeling) Islands
Colombia
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Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
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Dominican Republic
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Fiji
Finland
France
French Polynesia
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The Gambia
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Kenya
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Laos
Latvia
Lebanon
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Liberia
Libya
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Lithuania
Luxembourg
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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
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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
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Sudan
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
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Tonga
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Turkey
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Vanuatu
Vatican City
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Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Emergency Contact Information* This field is required.* 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
6
How did you hear about us?
Social Media
Google
Website
Referral
Drive By
Other
7
Who can we thank for your referral?
8
Date of Appointment* This field is required.
9
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.
10
Pet Information #1* 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
11
Is your pet microchipped?* This field is required.
YESNO
12
What is the number?
13
Does your pet show any reluctance to getting in the carrier or car?
Yes
No
14
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.)
15
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
16
Does your pet preferFemale Vet or Male Vet
Female veterinary professional
Male veterinary professional
It doesn't matter
17
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
18
How would you describe your pet around other animals and people?
19
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
20
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?
21
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital):
22
Does your pet like to play with toys? If so what kinds?
23
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?
24
Anything else you would like us to know?
25
Add a second pet?* This field is required.
YESNO
26
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
27
Is your pet microchipped?* This field is required.
YESNO
28
What is the number?
29
Does your pet show any reluctance to getting in the carrier or car?
Yes
No
30
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.):
31
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
32
Does your pet preferFemale Vet or Male Vet
Female veterinary professional
Male veterinary professional
It doesn't matter
33
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
34
How would you describe your pet around other animals and people?
35
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
36
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?
37
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital):
38
Does your pet like to play with toys? If so what kinds?
39
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?
40
Anything else you would like us to know?
41
Add a third pet?
YESNO
42
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
43
Is your pet microchipped?* This field is required.
YESNO
44
What is the number?
45
Does your pet show any reluctance to getting in the carrier or car?
Yes
No
46
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.):
47
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
48
Does your pet preferFemale Vet or Male Vet
Female veterinary professional
Male veterinary professional
It doesn't matter
49
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
50
How would you describe your pet around other animals and people?
51
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
52
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?
53
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital)
54
Does your pet like to play with toys? If so what kinds?
55
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?
56
Anything else you would like us to know?
57
Add a fourth pet?
YESNO
58
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
59
Is your pet microchipped?* This field is required.
YESNO
60
What is the number?
61
Does your pet show any reluctance to getting in the carrier or car?
Yes
No
62
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.)
63
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
64
Does your pet preferFemale Vet or Male Vet
Female veterinary professional
Male veterinary professional
It doesn't matter
65
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
66
How would you describe your pet around other animals and people?
67
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
68
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?
69
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital):
70
Does your pet like to play with toys? If so what kinds?
71
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?
72
Anything else you would like us to know?
73
May we request records from your previous veterinarian? * This field is required.
YESNO
74
What is the hospital name?
Hospital Phone number
75
Upload previous medical records
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
76
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
77
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.
78
Please print your name* This field is required.
79
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