New Client Form

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Welcome to our veterinary hospital and thank you for giving us the opportunity to care for your pet. We look forward to working with you in maintaining your pet’s health. Please complete the following as we would love to become better acquainted with you and your pet.

For all new clients we need to have your pets medical records submitted to us via email a week prior to your first appointment. Please email the records to: southeastanimalhospital@gmail.com
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Owner Details* This field is required.Pet Owner
First Name
Last Name
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Owner Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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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Mobile Phone
Other Phone
Owner Email
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Pet InformationPets Name
First Name
Last Name
Dog
Cat
Birds
Reptiles
Aquatics
Other
Species
If Other, Please Specify
Male
Female
Gender
Yes
No
Neutered/Spayed
Breed
Color
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Pet Information
Date of Birth or approximate age
Pet Insurance Information
Pet Food Brand
Cans
Dry
Other
Cans, Dry, Other
If Other, Please Specify
Amount (cups per day)
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Has your pet visited the vet within the past 3 years?
YESNO
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At which veterinary office can we find your pet's medical records?
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Routine Health Care ConcernsGeneral
Yes
No
N/A
Are your pet’s vaccines up to date?
Does your DOG get vaccinated against Lyme Disease?
Does your CAT go outdoors?
Do you expect to board your pet in the next year?
Does your pet make contact with other animals outdoors?
Is your pet on regular flea control during summer months?
Is your pet on a year-round heart worm preventative?
Has your pet had a heart worm test in the past year?
Has your pet been tested for parasites in the past year?
Do you travel with your pet?
Does your pet react to any vaccines, medications or food?
Are your pet’s vaccines up to date?
Does your DOG get vaccinated against Lyme Disease?
Does your CAT go outdoors?
Do you expect to board your pet in the next year?
Does your pet make contact with other animals outdoors?
Is your pet on regular flea control during summer months?
Is your pet on a year-round heart worm preventative?
Has your pet had a heart worm test in the past year?
Has your pet been tested for parasites in the past year?
Do you travel with your pet?
Does your pet react to any vaccines, medications or food?
Yes
No
N/A
Yes
No
N/A
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No
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No
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No
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No
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No
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No
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No
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Yes
No
Is your pet on any current medications?
Medications (dosage/frequency)
Yes
No
Does your pet have any chronic medical problems?
What are they?
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Yes
No
Has your pet had any illnesses, injuries or recent medical problems?
What are they?
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Routine Health Care Concerns cont'dHave you noticed any
Yes
No
N/A
vomiting, diarrhea or constipation?
gagging or choking?
coughing, sneezing, or wheezing?
stiffness, soreness or lameness?
itching, scratching or excessive licking?
scooting or licking rear end?
head shaking?
lumps or bumps?
unusual discharge from eyes or nose?
bad breath or body odors?
seizures or tremors?
vomiting, diarrhea or constipation?
gagging or choking?
coughing, sneezing, or wheezing?
stiffness, soreness or lameness?
itching, scratching or excessive licking?
scooting or licking rear end?
head shaking?
lumps or bumps?
unusual discharge from eyes or nose?
bad breath or body odors?
seizures or tremors?
Yes
No
N/A
Yes
No
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No
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No
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No
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No
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Have you noticed any changes in your pets
Yes
No
N/A
behavior?
eating or drinking habits?
frequency or amount of urination?
energy or activity level?
coat, hair, or skin?
weight (gain or loss)?
behavior?
eating or drinking habits?
frequency or amount of urination?
energy or activity level?
coat, hair, or skin?
weight (gain or loss)?
Yes
No
N/A
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No
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No
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No
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No
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No
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Reason for today's visit
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Authorization/Payment Policy:
Payment is due when services are completed or when patient is released. It is our policy to provide you with a written estimate of fees for any in-hospital treatment, surgery, or emergency care. If you have any questions regarding fees, we will be happy to discuss them with you at any time. We accept Visa, Master Card, Discover, American Express, and cash payments. We will also offer Care Credit and Scratchpay for qualified applicants.

I assume responsibility for all charges incurred in the care of my pet.
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Today's Date* This field is required.
Date
Year
Month
Day
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Signature* This field is required.
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