New Patient Form
Please use a new form for each new patient on file.
Client Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Today's Date
*
-
Month
-
Day
Year
Date
Pet Name
*
Is this a new patient?
*
Yes
No
Species
*
Please Select
Canine
Feline
Avian
Reptile
Rodent
Lagomorph
Mustelidae
Breed
*
Birth date or Approximate Age
*
Color
*
Reproductive Status
*
Male
Female
Neutered Male
Spayed Female
Has your pet been to any other veterinarians?
*
Yes
No
Name and Phone Number of Previous Veterinarian
What type of diet are you feeding your pet?
*
Does your pet have any food or environmental allergies that you are aware of?
*
Yes
No
Has your pet had allergy blood work done?
Yes
No
What type of Appointment are you here for today?
*
Please Select
Annual Exam
Wellness Exam
Vaccines
Sick
Injured
Surgical
Nail Trim
Anal Gland Expression
Health Certificate
Does your pet have any ongoing or new health issues that we should be aware of?
Is your pet currently on any medication?
*
Yes
No
Please list all current medications and when they are given
Does your pet need a refill of any medications today?
*
Yes
No
Please list any medications that need to be refilled
Would you like to sign up for our home delivery service for food and medications?
*
Yes
No
Has your pet had any coughing or sneezing?
*
Yes
No
How long has this been going on?
Has there been any discharge from the eyes?
*
Yes
No
What color is the eye discharge?
Please Select
Clear
Yellow
Green
Other
Has your pet been vomiting?
*
Yes
No
How long has this been going on?
Please give a short description of the vomit and how often this occurs
Has your pet had diarrhea?
*
Yes
No
How long has this been going on?
Have you noticed any bloody or tarry stool?
*
Yes
No
Has your pet traveled outside of the Puget Sound area within the last 6 months?
*
Yes
No
Please give details of travel (when, where, how long was the stay).
Do you have any concerns regarding your pets ears or skin?
*
Ears
Skin
Both Ears and Skin
No
Please give a short description about your concerns with your pets ears and/or skin
Do you have any other concerns you would like to discuss with the veterinarian
*
Yes
No
Please give a short description about your other concerns
We would love to see a picture of your pet, feel free to add as many as you'd like!
Browse Files
Drag and drop files here
Choose a file
Pictures will not be shared on our website or any social media platform without a consent form.
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Would you like us to share your pet on Social Media? (Instagram and Facebook)
Yes
No
Please fill out our Social Media Release form!
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