New Client/Patient Form

New Client/Patient Form

Duluth Animal Hospital
Welcome to Duluth Animal Hospital! We strive to provide excellent and personalized care to you and your pet. Thank you for trusting us with your pet's needs. Please fill out the following information for our records.
Your Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Alternate Phone Number (if applicable)
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Pet's Name*
Pet Type

DogCatBirdSmall Animal (hamster, guinea pig, rat, etc)Reptile (turtle, iguana, snake, etc)Other
Breed or Mix*
Select :*

MaleFemale
Spayed or neutered?*

NoYes
Color or Coat Pattern*
Ex. Tan, Merle, Calico, Black, etc
Pet's Birth Date (estimate if unsure)*

MonthDayYear
Date
Your Pet's Medical History
Does your pet drink from lakes, streams, or puddles? (ie during walks, hiking, outdoor play or living outside)*

YesNo
Please list any medications, supplements, or treatments your pet is currently on :
Has your pet had a past reaction to any medication, vaccine, or anesthesia?*

YesNo
If yes, please explain
Does you pet have any medical conditions or chronic diseases?*

YesNo
If yes, please explain :
Ex : Heart conditions, kidney disease, diabetes, arthritis, etc
If feline, does your cat spend time outside? (this includes balconies, porches, etc)*

YesNoNot applicable
When was your pet's last dose of Heartworm prevention given? (if unknown, leave blank)

MonthDayYear
Date
When was your pet's last dose of flea prevention given? (if unknown, leave blank)

MonthDayYear
Date
Authorization
If we may ask, how did you hear about us?*
If by recommendation, whom may we thank?
Your pet's prior medical history is crucial to understanding your pet's individual needs. It also prevents us from repeating any services or vaccinations your pet may not be due for. If you have not already provided your previous vet's information or emailed us your records, please be sure to send them to admin@duluthanimalhospital.com at least one day prior to your appointment.
I authorize the veterinarian to examine, prescribe medications for, and conduct treatments for my pet. I assume responsibiity for all charges incurred in the care of my animal. I also understand that full payment (Cash, American Express, Visa, Mastercard, Discover, or Care Credit) is due when services are rendered. Checks are not accepted.
Signature*

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New Client/Patient Form

Your Pet's Medical History

Authorization