New Client Form

New Client Form

Please complete the following form. If you have any questions please call or text us at 336-459-0874 or email cozypetvet@gmail.com
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number *
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.

Pets Information

	1st Pet	2nd Pet	3rd Pet	4th Pet	5th Pet	6th Pet
Pet's Name
Species
Breed
Color
Birthday or Age
Sex
Spayed/Neutered: Yes/No
Weight

Which pet(s) are you making an appointment for and what is the purpose of the appointment? *
Please give us a few dates and times you are looking to schedule for:
Has your pet had any previous serious illness or surgeries?
Has your pet had any allergies or reactions to vaccines or medications in the past?
We frequently give treats. Are there any treats we should avoid due to allergies (ex chicken, peanut butter)?
Is there any other information you would like to add? e.g. Does your pet display fear during exams or during certain procedures? Do they prefer to be examined on the floor?
Please list and explain concerns you would like to be addressed during the appointment and if your pet has been treated for these conditions in the past.
Will you need refills on any medications or prevention? (such as flea, tick, or heartworm prevention)
Do you give consent for images and/or videos of you and/or your pet(s) to be used on our website, social media pages, or promotional materials?
How did you hear about us?
Mode of communication preferred? (email, text, or phone call)
Cozy Pet Mobile Veterinary Care is a house call service. Services provided are those that can be done safely in the comfort of your home. We do not offer hospitalization, imaging (x-rays, ultrasound), surgery, emergency, or after hours care. Due to the nature of house calls all appointment times are approximate- please allow a one hour arrival window. *

I understand/agree
Normal business hours are Monday - Friday from 9am - 5pm. Messages are not monitored on the weekends or outside of normal business hours. Messages left after hours will be checked the following business day. There may be additional closures throughout the year for holidays, sick days, vacation, and continuing education. *

I understand/agree
Payment is due in full at the time of service. Payment forms accepted include cash, check, and credit card (Visa, Mastercard, American Express). We do not accept care credit, scratch pay, or offer payment plans. *

I understand/agree
Please email your pet's medical records to: cozypetvet@gmail.com or text a picture of the records to 336-459-0874 before your appointment so we may better serve you and your pet.
Should be Empty: