Welcome To Our Clinic
New Client Information Form
Client Name (Primary)
Street Address Line 2
State / Province
Postal / Zip Code
Home Phone Number
Do not put your cell phone number. If you do not have a home phone, please enter all 000-000-0000
Cell Phone Number (please enter all 0 if no cell phone)
Cell phone numbers only please.
Work Phone Number
If you do not have a work number you'd wish to share, please type all 000-000-0000
Client Name (Secondary, if applicable)
Client Phone Number (secondary)
Preferred number to reach if the primary person listed is not available.
How did you hear about us?
Date of appointment:
Please fill out one section for each pet.
Date Picker Icon
Is your pet altered? (spayed or neutered)
Patient Intake Form
Please answer the following questions to the nest of your knowledge. This form must be completed prior to your appointment.
Please enter the phone number we can call while you are here for your appointment.
To find you when coming to get your pet out of your car in the parking lot.
Scheduled Appointment Date
Scheduled Appointment Time
Primary Reason for Visit/Concerns. If any concerns, please state how long the issue has been going on for.
Please be as detailed as possible
Have there been any changes to the following?
None of the above
Please explain any abnormalities or changes you listed above.
What are you feeding your pet? Please list the names an types (wet, dry) of food and treats given to your pet throughout the day.
List all medications and supplements your pet is currently on, including doses.
This does include monthly preventative medication such as Heartgard or Nexgard
Are there any prior illnesses or injuries that we are not aware of?
Does your pet visit any of the following?
Boarding or Day Care
None of the above
Where does your pet spend most of his/her time?
Equal time Indoor and Outdoor
Do you have other pets at home? If yes, please list what kind below.
Is your pet current on his/her Rabies vaccination?
Are you or anyone in your household experiencing COVID like symptoms?
Have you been exposed to anyone with COVID?
Is there anything else we should know about your visit today?
Should be Empty: