Walther Animal Clinic

Walther Animal Clinic

New Pet/New Client Questionnaire
This questionnaire consists of four parts and will be used to collect information needed by the doctors and staff at Walther Animal Clinic to provide the best care for our patients. During your first visit, we will confirm all of this information with you.

The first section will ask general questions about you and your pet. Please answer to the best of the ability.
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
How did you hear about us?
Email
example@example.com
Pet's name
Pet species
Pet species
Pet breed
Pet color
Pet Birthdate, if known

Month Day Year
Date
Pet age (best guess is fine)
How long has your pet lived with you?
Where did you obtain your pet?
Pet sex
At Walther Animal Clinic, we treat all of our patients with care and respect. When possible, minimal restraint is used and treats are liberally given, when medically appropriate, to aide in keeping animal stress low. This MAY include products containing peanut butter.
Please select one of the following:

There are people with peanut allergies in the household. Please DO NOT feed my pet treats containing peanut butter. There are no known human food allergies in my household. It is ok to feed my pet treats containing peanut butter. There are no known human food allergies in my household, but I am not comfortable with my pet being fed treats containing peanut butter for other reasons. There are other allergies in my household (please specify)
There are other allergies in my household.
Please specify

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Walther Animal Clinic

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