NEW CLIENT JOT FORM

Medical History
Full Name*

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter Diet and Feeding information.*
Check the conditions that apply to your pet.*

Coughing and/or SneezingVomiting and/or DiarrheaEye ProblemEar ProblemLimpingLump or BumpChange in Thirst or AppetiteChange in Behavior or ActivityWeigh IssueNo concernsOther
How long has this condition been going on for and with what frequency?
Has your pet experienced this/these symptom(s) in the past? If so, when?
Does your pet have any reactions to vaccines or medications? Any other allergies?
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.
Please indicate what preventatives or medications you need a refill of:

Simperica TrioSimpericaProheart 12 (yearly heartworm injection)Advantage Multi (cats)Other
Which preventative care procedures are you approving? (Select all that apply)*

Rabies VaccineDistemper VaccineBordetella VaccineInfluenza VaccineLyme VaccineLeptospirosis VaccineIntestinal Parasite (Fecal) Lab testHeartworm/Tick Parasitology (Blood) testAnnual Full Organ Function Lab ScreeningUrinalysisOther
Any additional information you would like the team to know?
By signing this form I agree that I am the assigned owner/agent of the pet named above (s). The pet named above has not bitten anyone in the last 10 days. I also agree that payment will be made at the time of service. If left outstanding I understand that I will be liable for all fees and costs associated with that amount, including any third-party collection fees.

In Addition, any new client deposits are NON-REFUNDABLE, if the appointment is missed, and not rescheduled within a 24-hour window.
Signature*

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Medical History