New Client/Patient Form

Easton Animal Clinic

New Client/Patient Form
Date *

Month Day Year
Date
Appointment Date *

Month Day Year
Date
Name *

First Name Last Name
Name (if you would like to add a second contact)

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Phone Number (alternate)
Please enter a valid phone number.
Email *
example@example.com
New Pet Information
Name *

First Name Last Name
Have you been here before with other pets? Same or different last name? *
Phone Number *
Please enter a valid phone number.
Pet Name *
Age
Species *

Canine Feline Other
If other, please specify:
Sex *

Intact Male Neutered Male Intact Female Spayed Female
Breed *
Color *
For cats: Does your cat go outside?
Is your pet microchipped? *
Where did you get your pet? *
How long have you had him/her? *
What is your pet's current diet? Dry/canned, both? *
Amount and frequency of feeding? *
Does your pet have any previous history of vaccine reactions? *
Any history of medication reactions? *
Does your pet have any existing medical problems? Please list any/all medications and dosing. *
Please upload medical history, vaccine information here. If you are unable to do so, please bring the information with you for your appointment. We encourage you to have medical records faxed or emailed prior to your appointment to reduce wait time.

Cancel of
I acknowledge and agree first-time appointments are cash/credit only *

I agree
Medical History Questionaire
Pet Name *
Phone number *
What is the reason for your visit today? If a sick exam, please provide as many details as possible. *

Any changes in...? If yes to any changes, please explain in "Describe" field. *

Yes

Describe

Energy level

Appetite

Thirst

Urination

Defecation

Please list any additional details on changes (if YES) listed above.

Symptoms: If YES to any, please describe in "Explain" field. *

Yes

Explain when it started, how often, description, etc.

Sneezing?

Coughing?

Vomiting?

Diarrhea?

Itching/Scratching?

Joint pain/mobility problem?

Other

Please list any additional notes on symptoms listed above (if YES to anything or anything additional)
Any recent changes in diet/treats? *
Does your pet get table food? *
Is your pet on heartworm/flea/tick prevention? Please list which medications, frequency, and when last dose was given. *
Do you have any additional questions/concerns that you would like addressed during your visit? *

Consent for Curbside Services
I understand that I need to be reachable via phone at any time during my visit and remain in the parking lot in case an Easton Animal Clinic staff member calls regarding my pet's exam.

I understand I need to check-in for my appointment by phone at 732-246-2680 when I arrive in the parking lot. I need to arrive on time and understand that I will not be able to accompany my pet inside Easton Animal Clinic for their appointment. I also understand that if I arrive late for my appointment, my pet may not be able to be seen and I may need to reschedule my appointment.

Masks are required when bringing my pet to the door for their curbside appointment.

*Please be advised we may call you from a blocked number.*

*If you are unable to bring your pet to the door, or pick them up from the door please advise a team member who can pick your pet up from your vehicle then return them to you once the appointment is complete and payment is made.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Easton Animal Clinic

New Pet Information

Medical History Questionaire

Consent for Curbside Services