Heal Vet New Client Form
Your full name
*
First Name
Last Name
Pronouns
Address
*
Street Address
Unit or address note
City
State
Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
Do you want to add an alternate pet-parent or contact? This person will be allowed full access to medical records, able to make decisions for your pet's care, and will be copied on emails. You can update specific preferences later.
Yes
No
I may do this later
Co-parent name
First Name
Last Name
Co-Parent Pronouns
Co-parent email
Co-parent phone number
Format: (000) 000-0000.
How did you hear about us?
*
Please Select
One of our existing clients
Word of mouth
I saw the sign
Online reviews
Referral from another veterinarian
A shelter or adoption agency
Other (Please specify...)
Referral source
Who should we thank?
Pet name
*
If you have not named your pet yet it's okay to put "TBD"
Species
*
Please Select
Cat
Dog
Rabbit
Guinea Pig
Hampster
Rat
Other
Sex of Pet
Please Select
Female
Male
Not sure
Is your pet spayed or neutered
Yes
No
Not sure
Birthdate (or approximate age)
-
Day
-
Month
Year
Breed
Color
Please Select Any That Apply
I've had this pet less than a year
This is my very first pet
I've had other pets before this pet, but not recently
I have a lot of questions about pet care
My pet's care is complex
What is your pet like at the vet? Select ALL that apply:
My pet likes the vet / no behavior concerns
My pet is nervous or scared at vet visits
My pet may be (or has been) aggressive at vet visits
I am interested in / my pet has needed pre-visit medications for anxiety and/or aggression
My pet has needed full sedation for behavioral reasons at vet visits
I would like to discuss my pet's behavior concerns with a technician prior to my first visit
Other
Name of previous vet clinic
Phone number of previous vet clinic
Can we contact your previous vet for medical records?
Yes
No, I will contact them
Medical Records: Upload Here
Browse Files
Drag and drop files here
Choose a file
Please keep PDFs and photos under 2 MB
Cancel
of
Pet Photo: Upload Here
Browse Files
Drag and drop files here
Choose a file
Please keep photos under 2MB
Cancel
of
Do you want to add another pet? You can add info for one more now, and/or add more to our system later.
Yes
No
Pet name
Species
Please Select
Cat
Dog
Rabbit
Guinea Pig
Hampster
Rat
Other
Sex of Pet
Please Select
Female
Male
Not sure
Is your pet spayed or neutered
Yes
No
Not sure
Birthdate (or approximate age)
-
Day
-
Month
Year
Breed
Color
What is your pet like at the vet? Select ALL that apply:
My pet likes the vet / no behavior concerns
My pet is nervous or scared at vet visits
My pet may be (or has been) aggressive at vet visits
I am interested in / my pet has needed pre-visit medications for anxiety and/or aggression
My pet has needed full sedation for behavioral reasons at previous vet visits
Other
Name of Previous Vet
Phone Number of Previous Vet
Can we contact them for medical records?
Yes
No, I will contact them
Pet #2 Medical Records: Upload Here
Browse Files
Drag and drop files here
Choose a file
Please keep PDFs and photos under 2 MB
Cancel
of
Pet #2 Photo: Upload Here
Browse Files
Drag and drop files here
Choose a file
Please keep photos under 2MB
Cancel
of
Do any of your pets have an urgent medical condition, or general concerns we should know about?
What else would you like to share with us?
If we take a photo of your pet can we share it on social media?
Yes
No
Do we have permission to send your pet's medical records to ERs/Urgent Care?
*
Yes
No
Save for later
Submit
Should be Empty: