New Client Form
This form consists of five parts and will be used to collect information needed by the staff at Heather Ridge Pet Hospital to provide you and your pet(s) with the best care. During your first visit, we will confirm this information with you.
Name
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First Name
Last Name
Are there any other family members you would like listed on the chart?
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
How did you hear about us?
Pet's name
*
Pet species
*
Dog
Cat
Pet breed
*
Pet color
*
Pet Birthdate, if known
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Month
-
Day
Year
Date
Pet age (best guess is fine)
*
Pet sex
*
Male, intact
Male, altered
Female, intact
Female, altered
How long has your pet lived with you?
Where did you obtain your pet?
Breeder
Rescue/Humane Society
Family/Friend
Other
Do you have other pets in your household?
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Yes
No
Please list the name, breed, sex, and age of your other pets.
At Heather Ridge Pet Hospital, 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 better. Please select one of the following:
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There are people with peanut allergies in the household. Please DO NOT feed my pet treats containing peanut butter.
There are no known food allergies in my household. It is okay to feed my pet treats containing peanut butter.
There are no known 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 during appointment).
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Section 2/5
This section of the form will ask you questions about your pet's diet.
My pet's diet consists of (check all that apply):
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A commercial over-the-counter diet
A prescription Diet (please list type below)
A home-cooked diet
Raw meat
Vegetables
Table scraps
Treats
My pet's food is available:
*
At all times (Free Fed)
Only during specific meal times
Brand of diet, if known. Include brand and type of treats, if possible.
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Section 3/5
This section will ask you about you pet's medications, including heartworm and flea/tick prevention.
Is your pet currently taking any medications? (Including heartworm and flea/tick prevention, and any supplements)
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Yes (Please list medications below)
No
Please list names and dosages of medications and/or supplements your pet is currently on.
My pet is on heartworm prevention:
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Once per month year-round
Once per month seasonally
Mostly once per month, but some months get missed or skipped
My pet is not on heartworm prevention
Brand of heartworm prevention, if known:
My pet is on flea/tick prevention:
*
Once per month year-round
Once per month seasonally
Mostly once per month, but some months get missed or skipped
My pet is on a flea collar
My pet is not on flea/tick prevention
Brand of flea/tick prevention, if known:
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Section 4/5
This section will ask you about wellness and preventative care.
Microchip
*
My pet has a microchip and I know the registration number (please list below).
My pet has a microchip, but I don't know the registration number.
My pet does not have a microchip.
I don't know if my pet has a microchip.
Microchip number:
Oral Health (select all that apply)
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I brush my pet's teeth 3 times per week or more
I brush my pet's teeth at least once per week
My pet's teeth get brush while at the groomer's
I give my pet a tartar control food.
I give my pet a tartar control treat.
I give my pet dental chews
I use a water additive for oral health
I do not currently brush my pet's teeth or provide other oral health treatments such as chews, water additives, food or treats.
Rabies vaccine
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My pet is up to date
My pet is overdue
I don't know what my pet's rabies vaccine status is.
Can we contact your previous veterinarian to obtain medical records? This will help to provide seamless care from one facility to another.
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Yes
No
Please list the name and location of your previous veterinarian. If your pet does not have a previous medical history, please note that in the box.
*
Please check any health conditions your pet has been diagnosed with previously. Leave blank if your pet has never been diagnosed with a health condition before.
Ear infection
Periodontal disease
Heart murmur
Heart condition
Skin infection
Intestinal parasite
Intestinal obstruction
Obesity
Food allergy
Environmental allergy
Anxiety
Cancer (any kind)
Please select the activities that your pet participates in:
Grooming
Daycare/Boarding
Hunting
Hiking
Dog parks
Swimming in lakes/rivers/ponds
Do you have any particular concerns that you would like addressed by the veterinarian at your visit?
*
Your pet's experience and our staff's safety are of upmost importance. How would you rate your pet's behavior during prior visit to a veterinarian?
*
Please Select
Loves coming in
Apprehensive/scared but warms up
Very afraid - struggles during exam, may give "verbal" warnings like growling
Requires, or would benefit from, medications to reduce anxiety/level of stress at visits
Needs to be muzzled or requires full sedation
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Section 5/5
Client Policies and Procedures: We want you to be aware of and understand the following policies and procedures for all clients.
We Love Social Media! Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook and any other marketing and/or social media outlets we may choose to use?
*
Yes
No
Heather Ridge Pet Hospital uses email, text, phone calls, and postcards for communications regarding our patient's reminders for health care needs. Please select all of the types of communication you would like to receive:
*
Phone Call
Text Message
Email
Postcard
Financial Policy
Our office accepts Visa, Mastercard, Discover, and American Express. We also accept cash and checks (only with verification of valid drivers license or other ID at time of payment). Our office also offers Happy Healthy Pet (tm) Care Plans for preventive care treatments and procedures. You can find more information about these care plans at www.happyhealthypets.com/care-plans. In addition, we also offer several 3rd party financing options for our clients via Care Credit. We accept a variety of Care Credit plans based on the total transaction amount for your pet. Care Credit requires that payment only be made for services as they are rendered, we cannot charge services to your account in advance. Additionally, use of Care Credit requires that the card be present every time and that two forms of identification are verified. We appreciate your understanding of our desire to protect your account/identity. As financing options are offered, we cannot offer additional in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for Care Credit with a co-signer. Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. Client will be responsible for a monthly finance charge on accounts over 30 days and any collection and/or legal fees on accounts over 90days. Your signature below indicates your agreement with these policies.
Treatment Consent
TREATMENT CONSENT: By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Heather Ridge Pet Hospital to examine, prescribe for or treat the my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the except of another veterinary facility or grooming facility.
Signature
*
Submit
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