New Client Registration Form

We are currently only accepting new clients for non- urgent visits to establish patient care. This questionnaire consists of 1 page used to collect information needed by the doctors and staff at The Aurora Veterinary Clinic, Streetsboro Veterinary Center and Mantua Veterinary Clinic in order to provide the best care for our patients. During your first visit, we will confirm all of this information with you.

At our practice, we are committed to providing the highest standard of preventative care for your pet. A Rabies vaccine is required for all canine and feline patient at all of our locations. As well, Lyme disease is becoming increasingly common in our region and can have serious health consequences for dogs, we strongly recommend the Lyme vaccine as part of our core preventative care program.

During your visit, our veterinary team will discuss the benefits of Lyme vaccination and answer any questions you may have. Please be prepared to have a conversation about enrolling your dog in our Lyme vaccination protocol. Our goal is to work with you to make the best decision for your dog's long term health and protection.

Please answer the questions to the best of your ability.

Name

First NameLast Name

Today's Date

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

Additional Account Name (i.e. spouse/ partner)

First NameLast Name

Phone Number (i.e. spouse / partner)

Format: (000) 000-0000.

How did you hear about us?

Email

example@example.com

Do you already have an appointment?

If referral/ other, please specify:

Pet's name

Pet species

Pet breed

Pet color

Pet Birthdate, if known

Date

Pet age (best guess is fine)

How long has your pet lived with you?

Where did you obtain your pet?

What is the gender of your pet? Spayed or neutered?

**Please note: If your pet is coming in for a second opinion, please ensure the previous records have been received by our clinic within 48 hours of your appointment. If records have not been received from you or the previous veterinary facility within 24 hours of the appointment, the appointment will need to be rescheduled.**

Medical history:

Chronic conditions, allergies, medications, supplements

Any medical records can be emailed to auroraveterinary@gmail.com. Please provide us the name, phone number, city and state of your pet's previous veterinary clinic and phone number. If your pet hasn't been to a veterinary clinic yet, please bring any previous records with you to their appointment or upload in the section below.

Do you have insurance for your pet? If so, please provide insurance name:

Mutual Respect Agreement:

I understand that Aurora Animal Care Center is a healing environment, and respectful communication and collaboration between our team members and you, our client, is essential to provide optimal patient care. I understand that just as I would expect empathy, patience, honesty, and kindness from the team at AACC, our team is deserving of the same.

There is ZERO TOLERANCE for all forms of aggression and disruptive behavior both verbal and physical. Such behavior will result in termination of the veterinary-client-patient relationship.

Select to agree:

I am the owner and hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid in full, at the time of release of the pet.

Signature: