New Client Information
Contact Information
Please provide current and accurate contact information. Our doctors may need to call you for lab results or other important patient information. We send appointment confirmations and reminders by email and/or text message. We will not spam or share your email or cell phone.
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Primary Phone
*
Please enter a valid phone number.
Spouse / Significant Other / Alternate Contact
First Name
Last Name
Spouse / Significant Other / Alternate Phone
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Confirmation Email
example@example.com
Why did you choose us?
*
Website
Sign/Location
Used Us Previously
Personal Referral
Other
Personal Referral
Whom may we thank?
Pet Information
Patient Name
*
Patient Species
*
Dog
Cat
Other
Patient Sex
*
Female
Female Spayed
Male
Male Neutered
Patient Breed
*
Patient Color
*
Patient Birthday or Age
*
Last Vaccinated?
*
Do you have another pet to add?
*
Yes
No
Pet #2
Patient Name
*
Patient Species
*
Dog
Cat
Other
Patient Sex
*
Female
Female Spayed
Male
Male Neutered
Patient Breed
*
Patient Color
*
Patient Birthday or Age
*
Last Vaccinated?
*
Do you have another pet to add?
*
Yes
No
Pet #3
Patient Name
*
Patient Species
*
Dog
Cat
Other
Patient Sex
*
Female
Female Spayed
Male
Male Neutered
Patient Breed
*
Patient Color
*
Patient Birthday or Age
*
Last Vaccinated?
*
Medical Records
If possible please upload or bring previous medical records including vaccine history, lab work and Xrays to your visit. Also bring any medications your pet is currently taking or has previously taken.
Upload Records
Browse Files
Drag and drop files here
Choose a file
Cancel
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Is this appointment for a 2nd opinion on your pet's medical condition?
*
Yes
No
2nd Opinion - Yes
Describe the problem that is prompting you to seek a second opinion
*
How long has this been a problem?
*
How many other veterinarians have treated your pet for this problem?
*
Describe any previous diagnostic tests and the results if you know them.
List any previous medications or treatments for this problem and describe how your pet responded.
Payment Policy
Blue Springs Animal Hospital accepts
Our payment policy is "payment when services are rendered." How will you be paying for services at your appointment?
*
Credit or Debit Card
Personal Check
Cash
Other
Does your pet have pet health insurance?
*
Yes
No
Insurance Company
Insurance Company
We require an adult who is financially responsible for the pet to be present at the appointment. I am 18 years or older and I am financially responsible for this pet.
*
Yes
No
Notes or Special Instructions
Please verify that you are human
*
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