Eldorado Animal Clinic New Patient Form
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-
Month
-
Day
Year
Today's Date
Do you currently have an appointment with us?
*
Yes
No
Appointment Date
*
-
Month
-
Day
Year
Date
Owner's Name
*
First Name
Last Name
Additional Contact
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
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Please enter a valid phone number.
Cell Number
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Please enter a valid phone number.
Email
*
example@example.com
Employer
*
Work Number
*
Please enter a valid phone number.
Additional Contact Employer
*
Additional Contact Work Number
*
Please enter a valid phone number.
Who can we thank for referring you to this hospital?
*
PAYMENT IS EXPECTED AT TIME OF SERVICES.
FIRST PET INFORMATION
Animal Type
*
Dog
Cat
Other
Pet Name
*
First Name
Last Name
Breed
*
Color
*
Age
*
Sex
*
Spayed or Neutered?
*
Yes
No
Any major surgeries we should know about?
*
If yes, please provide procedure, date and any other details.
Any chronic problems we should know about?
*
Is your pet taking any continual medication?
*
Approximate date of last immunization:
Canine Distemper
*
-
Month
-
Day
Year
Date
Canine Parvo
*
-
Month
-
Day
Year
Date
Rabies
*
-
Month
-
Day
Year
Date
Feline FVRCP
*
-
Month
-
Day
Year
Date
Feline Leukemia
*
-
Month
-
Day
Year
Date
Approximate date of last heartworm check:
*
-
Month
-
Day
Year
Date
Approximate date of last Feline Leukemia check:
*
-
Month
-
Day
Year
Date
Other
Please list immunization name and date
Anything else you would like us to know?
Would you like to add another pet?
*
Yes
No
SECOND PET INFORMATION
Animal Type
*
Dog
Cat
Other
Pet Name
*
First Name
Last Name
Breed
*
Color
*
Age
*
Sex
*
Spayed or Neutered?
*
Yes
No
Any major surgeries we should know about?
*
If yes, please provide procedure, date and any other details.
Any chronic problems we should know about?
*
Is your pet taking any continual medication?
*
Approximate date of last immunization:
Canine Distemper
*
-
Month
-
Day
Year
Date
Canine Parvo
*
-
Month
-
Day
Year
Date
Rabies
*
-
Month
-
Day
Year
Date
Feline FVRCP
*
-
Month
-
Day
Year
Date
Feline Leukemia
*
-
Month
-
Day
Year
Date
Approximate date of last heartworm check:
*
-
Month
-
Day
Year
Date
Approximate date of last Feline Leukemia check:
*
-
Month
-
Day
Year
Date
Other
Please list immunization name and date
Anything else you would like us to know?
Would you like to add another pet?
*
Yes
No
THIRD PET INFORMATION
Animal Type
*
Dog
Cat
Other
Pet Name
*
First Name
Last Name
Breed
*
Color
*
Age
*
Sex
*
Spayed or Neutered?
*
Yes
No
Any major surgeries we should know about?
*
If yes, please provide procedure, date and any other details.
Any chronic problems we should know about?
*
Is your pet taking any continual medication?
*
Approximate date of last immunization:
Canine Distemper
*
-
Month
-
Day
Year
Date
Canine Parvo
*
-
Month
-
Day
Year
Date
Rabies
*
-
Month
-
Day
Year
Date
Feline FVRCP
*
-
Month
-
Day
Year
Date
Feline Leukemia
*
-
Month
-
Day
Year
Date
Approximate date of last heartworm check:
*
-
Month
-
Day
Year
Date
Approximate date of last Feline Leukemia check:
*
-
Month
-
Day
Year
Date
Other
Please list immunization name and date
Anything else you would like us to know?
Previous Veterinary Record(s)
Browse Files
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Please upload any medical history you may have from your previous veterinarian(s).
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Pet Parent Signature
*
By signing this form, I acknowledge that I am the legal owner of the pet(s) listed above, and that I am financially responsible for their care.
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