New Patient Application Form

New Patient Application Form

This application form will help us to asses if we are a good fit for your needs, and will help us provide the most personalized care for your companion animal and your family! If we are seeing more than one of your companion animals please fill one form for each animal. Additionally, if you have any past medical records, feel free to send them to castilloanimalvc@gmail.com. Thank you so much in advance for taking the time to fill this out and looking forward to serving you.
Name of your companion animal *

First NameLast Name
Species*
Breed*
Age*
Gender*

Intact femaleSpayed femaleIntact maleNeutered male
Color*
Microchip number
What issues or concerns do you have about your companion animal? What would you like help with? *
Has your companion animal been examined elsewhere for the same condition?If yes, where?*
What food are you currently feeding, please specify brand?*
What medication(s) is your companion animal taking now?*
What flea/heartworm prevention is using?*
Does your companion animal have any history of biting a person or another animal?*
Is your companion animal having any vomiting or diarrhea?*
Is your companion animal having any changes in eating or appetite?*
Is your companion animal lethargic?*
Is your companion having any excessive or unusual coughing or sneezing?*
Is your companion animal experiencing any changes in urination or drinking?*
Is your companion animal itchy or shaking her/his head?*
Is your companion animal experiencing any pain, limping, or mobility issues that you know of? *
Does your companion animal have any allergies to foods or medicines? Are there any treats he/she can not have? *
Where is your companion animal coming from? (Shelter, rescue, etc.)*
Are you the legal guardian(owner) of this companion animal?*
Do you have pet health insurance?*
Are your companion animals’ vaccinations up to date?*
Was there a heartworm test performed in the last year?*
Is your companion animal taking heartworm prevention?*
Has your companion animal been tested for worms in the last year?*
Has your companion animal had any illness/injury in the last year?*
Has your companion animal ever had a seizure?*
Does your companion animal get table scraps?*
Other important info:
Do you have parking available close to the entrance of your home? If not, what is the best place to park around your home?*
Are there any stairs to get to your main door?*
How did you hear about us? (Facebook, Word of mouth, Google, etc.)
Name*

First NameLast Name
Email*
example@example.com
Should be Empty:

New Patient Application Form

Other important info: