New Client Form for Small Mammal

New Client Form

Thank you for the opportunity to care for your beloved pet. Our goal is to treat your pet with the same love and quality care that we would with our own, and to provide the highest quality service. We take an integrative approach for the best health care with strong emphasis on nutrition as a base for excellent health. Please help us meet your needs and the needs of your pet by sharing the following important information:

Pet Owner's Name: First Name * Last Name *

Address: Street Address
City   State   Zip

Home Phone:    Phone Number Cell Phone: Phone Number

Email Address:   Email *

Employer:      Work Phone: Phone Number

Significant Other or Co Owner:

Name:First Name Last Name

Cell Phone: Phone Number

Email Address: Email

Emergency Contact:

Name:First Name Last Name

Cell Phone: Phone Number

How did you hear about us?: *

Or referred by (We would like to thank them):

May we take photographs of your pet(s) for educational purposes or for our social media? We will not release personal information such as your name :

Yes No

Pet's Name:

Date of Birth/Approximate Age:

Species: *

Breed:

Color/Markings:

Sex:

Female Spayed Female Male Neutered Male

Where and when did pet come to be in your family?:

Are there other pets in your household?:

Yes No

If Yes, please indicate quantity:

Dogs: # Cats: #

Birds: # Reptiles: #

Other (Please specify):

Origin Source (Breeder, Pet Shop, etc):

What type of cage / enclosure does your pet have and approximate size?:

Where in the house is the enclosure located?:

Does your pet spend time outside the enclosure?:

Yes No

If Yes, How much? / Where?:

Are other pets sharing the enclosure, or in direct contact?:

How often is the enclosure cleaned, and what products are used?:

What kind of food do you feed your pet?
Please specify types/brands and how often of each:

Brand/Type: name   How often/much: frequency

Brand/Type: name   How often/much: frequency

Brand/Type: name   How often/much: frequency

Dry Food / Pellets?:
Brand: name How often/much: amount

Hay? (if applicable) :

Vegetables / Fruits?:

Treats?:

Other?:

Ex: protein

Do you give your pet suppliments?
Please specify types/brands and how often of each:

Brand/Type: name   How often/much: frequency

Brand/Type: name   How often/much: frequency

Brand/Type: name   How often/much: frequency

Please list any previous medical problems:

Does your pet have any behavior problems?:

Have you noticed any of the following?
If so, please describe:

Decreased appetite / Increased appetite:

Weight gain / Weight loss:

Vomiting / Diarrhea:

Difficulty breathing:

Lethargy:

Nasal or Eye Discharge:

Have there been any changes in your pet's stool droppings? Please Describe:

(number, color, consistency).

FERRETS ONLY: Has your ferret ever been vaccinated for rabies or ferret distemper?:

Yes No

FERRETS ONLY: If so, have they ever had a vaccine reaction?

Name of Hospital/Clinic where records can be obtained?:

Hospital/Clinic: name * Phone: #*

Email: email

*Many hospitals/clinics require owner release of their pet's records

Does your pet have Microchip Identification?:

Yes No

We believe in all pets being microchipped. Would you like more information on this?:

Is your pet covered under any pet insurance?:

Yes No

Would you like information on Veterinary Pet Insurance?:

Is there anything else you would like to mention or have concerns about?:

We gladly provide a written Health Care Plan with associated professional fees. This will be important to you since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge, we accept Visa, Mastercard, American Express, Discover, or Care Credit.

Dear Fur & Feather Veterinary Hospital Clients:

We are asking that our clients please call in advance if unable to keep a previously scheduled appointment, including boarding reservations, grooming and drop-off appointments. Clients who need to schedule an appointment for their pets, especially a sick pet, appreciate the opportunity to utilize the available appointment time and obtain the care that their pet needs.

This letter notifies our clients that a $65.00 Missed Appointment Fee will be billed to the account if a courtesy cancellation call is not received 24 hours prior to the booked appointment time.

We thank you for trusting our team to provide the very best care for your beloved pets. We value you and our patients. If you have any questions, please feel free to ask to see me or just give me a call.

Sincerely,

Hospital Administrator

I have received a copy of this notice and I understand the above policy.

Client Name: First Name * Last Name *

Client Signature: *

Clear

Date:

Date

PET INFORMATION

Identification

Pet Insurance