Hardyston vet - New Client Form

1
Welcome to our veterinary clinic 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.
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Owner Details* This field is required.Pet Owner
First Name
Last Name
3
Owner Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
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Australia
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The Bahamas
Bahrain
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Brazil
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Burundi
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Cayman Islands
Central African Republic
Chad
Chile
China
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Croatia
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Cyprus
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Denmark
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Dominican Republic
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Egypt
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Equatorial Guinea
Eritrea
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Ethiopia
Falkland Islands
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The Gambia
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Iran
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Israel
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Jamaica
Japan
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Kenya
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North Korea
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Kosovo
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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
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Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Singapore
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Solomon Islands
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South Ossetia
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eSwatini
Sweden
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Syria
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Tajikistan
Tanzania
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Tonga
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Turkey
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Vatican City
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Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Mobile Phone
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Please Select
Yes
No
Can we communicate with you via text?
Other Phone
Owner Email
5
Pet InformationPets Name
First Name
Last Name
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Please Select
Dog
Cat
Other
Species
If Other, Please Specify
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Please Select
Male
Female
Gender
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Please Select
Yes
No
Neutered/Spayed
Breed
Color
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Pet Information
Date of Birth or approximate age
Pet Insurance Information
Pet Food Brand
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Please Select
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?* This field is required.
YESNO
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At which veterinary office can we find your pet's medical records?
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Routine Health Care Concerns* This field is required.General
Yes
No
N/A
Are your pet’s vaccines up to date?
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Does your DOG get vaccinated against Lyme Disease?
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Does your CAT go outdoors?
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Do you expect to board your pet in the next year?
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Does your pet make contact with other animals outdoors?
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Is your pet on regular flea control during summer months?
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Is your pet on a year-round heart worm preventative?
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Has your pet had a heart worm test in the past year?
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Has your pet been tested for parasites in the past year?
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Do you travel with your pet?
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Does your pet react to any vaccines, medications or food?
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Row 10, Column 1
Row 10, Column 2
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
Row 0, Column 0
No
Row 0, Column 1
N/A
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
N/A
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
N/A
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
N/A
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
N/A
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
N/A
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
N/A
Row 6, Column 2
Yes
Row 7, Column 0
No
Row 7, Column 1
N/A
Row 7, Column 2
Yes
Row 8, Column 0
No
Row 8, Column 1
N/A
Row 8, Column 2
Yes
Row 9, Column 0
No
Row 9, Column 1
N/A
Row 9, Column 2
Yes
Row 10, Column 0
No
Row 10, Column 1
N/A
Row 10, Column 2
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Please Select
Please Select
Yes
No
Is your pet on any current medications?
Medications (dosage/frequency)
Please Select
Please Select
Yes
No
Does your pet have any chronic medical problems?
What are they?
11
Please Select
Please Select
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'd* This field is required.Have you noticed any
Yes
No
N/A
Vomiting, diarrhea or constipation?
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Gagging or choking?
Row 1, Column 0
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Coughing, sneezing, or wheezing?
Row 2, Column 0
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Stiffness, soreness or lameness?
Row 3, Column 0
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Itching, scratching or excessive licking?
Row 4, Column 0
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Scooting or licking rear end?
Row 5, Column 0
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Row 5, Column 2
Head shaking?
Row 6, Column 0
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Lumps or bumps?
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Unusual discharge from eyes or nose?
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Bad breath or body odors?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Seizures or tremors?
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
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
Row 0, Column 0
No
Row 0, Column 1
N/A
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
N/A
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
N/A
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
N/A
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
N/A
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
N/A
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
N/A
Row 6, Column 2
Yes
Row 7, Column 0
No
Row 7, Column 1
N/A
Row 7, Column 2
Yes
Row 8, Column 0
No
Row 8, Column 1
N/A
Row 8, Column 2
Yes
Row 9, Column 0
No
Row 9, Column 1
N/A
Row 9, Column 2
Yes
Row 10, Column 0
No
Row 10, Column 1
N/A
Row 10, Column 2
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Have you noticed any changes in your pets* This field is required.
Yes
No
N/A
Behavior?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Eating or drinking habits?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Frequency or amount of urination?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Energy or activity level?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Coat, hair, or skin?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Weight (gain or loss)?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Behavior?
Eating or drinking habits?
Frequency or amount of urination?
Energy or activity level?
Coat, hair, or skin?
Weight (gain or loss)?
Yes
Row 0, Column 0
No
Row 0, Column 1
N/A
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
N/A
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
N/A
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
N/A
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
N/A
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
N/A
Row 5, Column 2
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Reason for today's visit* This field is required.
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How did you hear about us ?
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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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1st Preferred Date Date * and preferred Time *
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2nd Preferred Date Date * and preferred Time *
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3rd Preferred Date Date * and preferred Time *
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Signature* This field is required.
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