New Client Information Form

Primary Owner Name *

First Name Last Name

Other Owner Name

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Primary Phone (mobile preferred) *

Please enter a valid phone number.

Secondary Phone

Please enter a valid phone number.

Primary email address *

example@example.com

Secondary email address

example@example.com

Primary Owner Date of Birth *

Date

Name of Pet *

Type of Pet *

Breed of Pet *

Age of Pet or Pet's Date of Birth *

Sex of pet *

What are the pets current health concerns you would like addressed?

Name and location of previous veterinary clinic. May we reach out for records?

Date of Last Exam

Date of Last Rabies vaccination (cats and dogs)

Date of last Distemper/Parvo vaccination (Dogs)

Date of last Bordetella vaccination (dogs)

Date of last Influenza vaccination (dogs)

Date of last Leptospirosis vaccination (dogs)

Date of last FVRCP vaccination (cats)

Date of last Feline Leukemia vaccination (cats)

Has your pet received any other vaccinations?

Date of last heartworm test (dogs)

Is your pet on a heartworm preventive medication?

yes no

Brand of Heartworm Preventive Medication

Is your pet on a flea or flea/tick preventive medication?

yes no

Brand of Flea or Flea/Tick Preventive Medication

Is your pet on any other medications? Please list if yes.

Do you have pet insurance? If so, please list company and policy number.

Does your pet have a job other than being a pet, for example hunting, livestock guardian, etc?

What does your pet eat? Brand and volume of food? Treats?

Where did you obtain your pet?

How long have you owned your pet?

Where does your pet live?

Inside only Indoor/Outdoor Outside

Does your dog:

go to the dog park go to the groomer board at a kennel go to training classes go camping go hiking have exposure to livestock

For female dogs that are not spayed, when was the last heat cycle (approximation is fine)?

When (at what age) was your pet spayed or neutered?

Does your pet have any food allergies? If so please list.

Has your pet ever had any bad reactions to medications?

Has your pet had an injury or illness prior to the current problem? Have they ever had surgery other than spay or neuter?

If you have records from a previous veterinarian please upload PDF documents here.

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I acknowledge the following policies (please check that you have read each policy):

My payment options will be cash, check, or Venmo and I will be prepared to make payment at the time of service. I will be charged a cancellation fee of $75 if I cancel my appointment with less than 24 hours notice. I will be charged the travel fee plus the cancellation fee if I do not show up for my scheduled appointment. I will be charged a waiting fee of $2/minute if I am not prepared and my pets are not contained while Dr. Burnett and her staff wait. I will be charged an animal handling fee $3/minute if Dr. Burnett and her staff have to search for my pet around the house because it was not contained. Emergencies will incur an additional emergency fee of $150.

Signature: *

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