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Shuler VC - New Client Form
1
Primary Owner
Secondary Owner
Email Address
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2
Address
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Street Address
Unit Number
City
State / Province
Postal / Zip Code
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United States
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American Samoa
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Latvia
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Libya
Liechtenstein
Lithuania
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Mali
Malta
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Morocco
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Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
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Nigeria
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Northern Mariana
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Oman
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Palau
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Panama
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Poland
Portugal
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Romania
Russia
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Saint Helena
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Saint Lucia
Saint Martin
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Samoa
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Serbia
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Slovenia
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Somalia
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Spain
Sri Lanka
Sudan
Suriname
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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
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
Curaçao
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
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3
In order of preference below, please list contact information
Primary Contact
Phone Number
Secondary Contact
Phone Number
Alternate Contact
Phone Number
Alternate Contact
Phone Number
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4
Preferred mode of contact for reporting *normal* lab results
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Email
Call
Text
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5
How did you first hear of us?
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Social Media
Google Search
Drove By
Personal Referral
Other
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6
Please provide us the name of the individual we can thank.
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7
If Other, Please Specify
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8
Disclaimer
*
This field is required.
By checking this box, I hereby authorized the veterinarian to examine, prescribe for, and/or treat the animal(s) described in this form. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.
In the future, I may request that my pet’s consolidated medical information or entire medical chart be transferred elsewhere (kennel, groomer, daycare, another veterinarian, other). I understand that the medical chart is a legal document that may also contain sensitive information about me and by requesting the transfer of my pet’s medical record, I am authorizing the release of its contents.
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9
Social Media Opt-Out
Shuler Veterinary Clinic would like your permission to use images taken of your pet on our website and social media outlets. If you do not consent to have your pet's picture used, please check this box.
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10
Pet Health History
*
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Name
Birthdate
Breed
Color
Male
Female
Male Neutered
Female Spayed
Male
Female
Male Neutered
Female Spayed
Gender
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11
Previous Vet
Purpose Of Last Visit
Date Of Last Visit
Date Of Last Vaccines
Vet's Phone
Vet's Website
Yes
No
Yes
No
Has your pet ever been sick after receiving vaccinations?
Yes
No
Yes
No
Is your pet on heartworm prevention?
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12
Is your pet on flea and tick prevention?
Yes
No
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13
Is your pet currently taking any long term medications? If so, please list.
Please list all food sources, brands, and treats that you are feeding your pet.
If your pet has a history of ear infections, skin infections, or hair loss, please describe
If your pet has ever experienced a serious illness, please describe
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14
Has your pet ever been diagnosed with any of the following conditions?
Heartworm Disease
Adrenal Gland Disease
Diabetes
Thyroid Gland Disease
Other
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15
If Other, Please Specify
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16
If your pet has ever suffered from an injury requiring emergency care, please explain
Please list any previous surgeries your pet has had, along with the date of the procedure
If your pet has ever experienced a seizure, please describe
Does your pet exhibit any concerning behaviors (barking, inappropriate urination, etc.)?
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17
Bone and Joint Health
Please check all that apply
Difficulty climbing up or down stairs
Stiffness or limping
Difficulty rising from sitting or resting position
Diagnosed with osteoarthritis, elbow or hip dysplasia, cruciate disease of the knees
Lags behind on walks
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18
General Health Questions
Please check all that apply
Bad breath
Allergies (fleas, food, pollen, etc.)
Increased drinking/urination/eating
Unexplained weight change
Vomiting
Diarrhea or constipation
Change in activity level or association with family members
New environment or environmental dynamics (new family member, sleeping arrangements, litter, work/play schedule, etc.)
Coughing/sneezing/shortness of breath
Panting even while resting
Confusion or disorientation
Change in sleeping patterns (sleeps more or less, night vocalizing or pacing)
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19
Please Specify, Vomiting Frequency
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20
Please Specify, Diarrhea Frequency
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21
Do you have pet insurance or any interest in discussing pet insurance plans?
*
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Yes
No
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22
Is there anything specific you would like us to know about your pet today, or do you have any concerns you would like to discuss?
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