Patient and Client Information

Patient and Client Information

Welcome to Cortaro Farms Pet Hospital! We want to provide your pet with the highest quality and most personalized veterinary care possible. Please help us with this by completing the form below. Thank you!
Current COVID-19 Policy
- Call from your vehicle when you arrive in our parking lot to check-in first.
- At this time only 2 owner will be allowed into the hospital (exceptions made for end of life exams).
- Face mask are required in our hospital regardless of vaccination status .
- Due to the limited space in the examination rooms we will exam your pet in our treatment area and once the veterinarian has completed their exam they will bring your pet back to the exam room discuss their recommendations with you.
- We are still giving owners the option to stay in their vehicle for curbside check-in, just let the front desk know you would prefer this when you check in.
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I understand and agree to the COVID-19 policies
Owner Name: *

First Name Last Name
Spouse / significant other:

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone *
Mobile or Home Phone: *

Mobile House phone
Secondary phone:
Work Number:
Email: *
example@example.com
Additional authorized adults on your pets account:
How did you hear about us?
Patient Information
Pet's Name: *
Species: *

Feline Canine
Breed: *
Do NOT put MIXED or MUTT
Color: *
Birth Date (if unsure estimate): *

Month Day Year
Sex: *

Male Female
Spayed or Neutered? *

Yes No Unsure
Date of last vaccinations: *
If your pet has no vaccinations yet enter NONE
Does your pet have a microchip? *

Yes No Unsure, please check
Has your pet been experiencing any of the following?

Coughing Vomiting Diarrhea Excessive urination Excessive drinking Decreased appetite Lethargy / weakness New lump / old lump that has increased in size Weight loss Foul odor from mouth / painful mouth Ear issue (pain, red, or bad odor) Other
Does your pet have any known allergies or vaccine reactions? If yes please list:
What medications or supplements does your pet take? (drug, dosage, frequency)
Previous veterinarian or vaccine clinic: *
NONE if your pet has not been to a veterinarian or vaccine clinic yet
Is there any further information you would like to add to better prepare us for your pets appointment? Any triggers we should be aware of?
Would you like any of these services during your pets appointment?

Anal gland expression - $46.50 Nail Trim - $19.00 Heartworm Test - $53 Flea/tick/heartworm prevention - prices vary Pet fix program for low cost spay and neuter clinics
We would love to share our new patients on our social media outlets as well as any unique or interesting cases, do we have your permission to publish photographs relating to your pets experience in our hospital? *

Yes No
To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on vaccines and free from parasites. Vaccines and parasite control will be provided as needed.

Financial Responsibility: Profressional fees are due when services are rendered at each visit without exception. You will be charged for any costs associated with the collection of any amount outstanding, and you agree to this policy by signing below. If you need financial assistance, please ask our receptionist about Care Credit and ScratchPay before your pets scheduled appointment.
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By checking this box I agree to the above terms and conditions
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Patient and Client Information

Patient Information