Have you ever brought any of your pets to El Dorado Animal Clinic before?
*
Yes
No
Owner's Name
*
First Name
Last Name
Email
*
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Would you like to take a moment to update your information for our records?
Yes
Not right now
Owner's Date of Birth
Owner's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Credit Policy: We ask that all fees be paid at the time of service. We accept cash, personal checks (with identification), Visa, MasterCard, Discover, American Express, and CareCredit. Exceptions must be cleared with the Practice Manager prior to service. Past due accounts are subject to late fees and those turned over to collections are subjection to collection and/or legal fees.
*
I have read this statement and understand
Social Media/Photo Permission: Do we have your permission to post photos of your pet online?
*
Yes
No
Would you like to add a second person to the account?
*
Yes
No
Spouse/Secondary Owner Name
First Name
Last Name
Spouse/Secondary Owner Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Thank you for taking the time to update our records! We appreciate your patience.
Will this be the first visit to El Dorado Animal Clinic for this specific pet?
*
Yes
No
Which pet will we be seeing?
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
Would you like to add information for a second pet?
*
Yes
No
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
Would you like to add information for a third pet?
*
Yes
No
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
Would you like to add information for a fourth pet?
*
Yes
No
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
Would you like to add information for a fifth pet?
*
Yes
No
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
Would you like to add information for a sixth pet?
*
Yes
No
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
Would you like to add information for a seventh pet?
*
Yes
No
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
Would you like to add information for a eighth pet?
*
Yes
No
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
Would you like to add information for a ninth pet?
*
Yes
No
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
Would you like to add information for a tenth pet?
*
Yes
No
Pet's Name
*
Species
*
Canine
Feline
Other
Breed
Color
Date of Birth/Age
Gender
*
Male
Female
Unsure
Spayed or Neutered?
*
Yes
No
Unsure
Any Known Allergies/Reactions?
*
Yes
No
If Yes, Please Elaborate:
Is your pet's Rabies vaccination up to date?
*
Yes
No
Unsure
When was the last time your pet was seen by a veterinarian?
*
Who was your pet's previous veterinary clinic?
*
How Would You Like To Receive Reminders for Your Pet's Care?
*
Email
Text Message
Post Card
Phone Call
I would not like to receive reminders
Submit
Should be Empty: