Shaffer AH - New Patient Form

1
Owner First & Last Name
First Name
Last Name
2
Phone Number* This field is required.
Please enter a valid phone number.
3
Email* This field is required.
example@example.com
4
Pet Information
Pet's Name
Species
Breed
Male
Male/Neutered
Female
Female/Spayed
Sex
5
As a Fear Free Certified Professional team, we want to make you pet’s veterinary experience as enjoyable and as stress free as possible. As such, it’s important for us to understand what your pet might find upsetting. The information will help us to adjust our care to better serve and comfort your pet. Please answer the following questions to the best of your ability so we can take into consideration both your & your pet’s preferences.
6
Yes
No
Does your pet show any reluctance to getting in the carrier or car?
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.)
7
During travel to the veterinary hospital, does your pet do any of the following
Eager & excited
Reluctant
Hide
Drool
Vomit
Urine/BM
Subdued
Bark/Meow
Whine
Pant
Tremble
Pace
8
Does your pet prefer
Female veterinary professional
Male veterinary professional
It doesn't matter
9
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end.
Getting in their carrier or the car
Entering the veterinary hospital
Other pets and/or people passing by while in reception/check-in
Waiting with other people and animals in the waiting area
Being approached by veterinary staff
Getting on the scale for a weight
Hearing the doorbell, overhead intercom, or phones ringing
Sounds coming from the back areas of the practice
Going into the exam room
Being put up on the table for examination
Having direct eye contact with the technician and/or veterinarian
Loud voices during examination
Having a rectal temperature taken
The use of instruments such as the stethoscope or otoscope (to look in the ears)
Being taken out of the exam room for procedures
10
How would you describe your pet around other animals and people?
11
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
12
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) If so, how did you pet react?
13
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital)
14
Does your pet like to play with toys? If so what kinds?
15
Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience?
16
Anything else you would like us to know?
Should be Empty: