PBVC Welcome Sheet

ATTENTION: PLEASE ONLY FILL OUT THIS FORM IF YOU ALREADY HAVE AN APPOINTMENT SCHEDULED AT OUR CLINIC.

THANK YOU!

Welcome!

Thank you for giving the Point Breeze Veterinary Clinic the opportunity to care for your pet. To ensure the best care possible, please take the time to fill out this form in its entirety.

Thank you!
Date of Appointment

MonthDayYear
Date
Owner Name*

First NameLast NamePronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate whether this is a:

Home phone (landline)Cell phoneWork phone
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate whether this is a:

Home phone (landline)Cell phoneWork phone
Email (for clinic use only)
example@example.com
What is your preferred method of communication from the office?*

Phone CallTextEmail
If you prefer texting, who is your cell phone provider? (Verizon, AT&T, T-Mobile, etc.)
Spouse, Partner, or Emergency Contact Name

First NameLast Name
Spouse, Partner, or Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you learn about our clinic?

InternetReferralOther
If you were referred, please let us know by whom:
Pet Health History
Name of pet:*
Species (feline/cat or canine/dog):*
Species*

Feline/catCanine/dog
Breed or mix:*
Color:*
Birthdate:

MonthDayYear
Date
Gender:*
Spayed (female pet) or Neutered (male pet)?*

YesNo
Vaccination history (date and type of last vaccinations). Please disregard if your pet's medical records have been transferred digitally already.
Please check any symptoms or problems that you have noticed about your pet:

Behavior issuesBleeding gumsBreathing issuesCoughingDiarrheaEye issuesGaggingLack of appetite/anorexiaLimpingLoss of balance/coordinationScootingScratching/skin issuesDepression/lethargyShaking head/ear issuesSneezingExcess thirst or urinary issuesVomitingWeaknessOther
Please list your pet's current medications, including any flea/tick or heartworm prevention, or over-the-counter medications:
Describe your pet's diet, including brand and type (kibble, wet food, etc.):
May we feed your pet treats, peanut butter, and/or squeeze cheese?*

YesNo
Please list any food allergies or intolerances at home to avoid feeding:
AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe for, and otherwise treat the above described pet. I assume responsibility for all charges incurred in the care of this pet. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.
Signature*
Today's Date*

MonthDayYear
Date
I grant Point Breeze Veterinary Clinic, Inc., permission to post my pet's picture, story, and medical information on social media. Please initial if true.
The following forms of payment are accepted: Cash, Checks, Visa, MasterCard, DiscoverCard, American Express, e-Checks
Should be Empty: