Registration Form

Medical History Questionnaire
Today's Date*

MonthDayYear
Date
Appointment Date*

MonthDayYear
Date
Current Client Relationship:*
Owner's Name*

First NameLast Name
Pet's Name*
Choose One*

CanineFeline
Reason For Visit:*
Choose One

History- If abnormal, please add notes below*

	Normal	Abnormal
Energy Level
Appetite
Thirst
Urination
Defecation

Additional Notes:
Does your cat go outside?*

YesNo

History- If yes, please add notes below (How long? How often?)*

	No	Yes
Sneezing?
Coughing?
Masses/Growths?
Vomiting?
Diarrhea?
Itching?

Additional Notes:
Name of diet fed and how much daily:*
Medications and heartworm/flea prevention pet is currently on (include dosages and frequency)*

Previous History- If yes, please add notes below*

	No	Yes
Any Adverse Vaccine Reaction?
Any Adverse Medication Reaction?
Any Adverse Anesthesia Reaction?
Previous Diagnosis/Medical Condition?
Any Previous Surgeries?

Additional Notes
Are there any other problems that you would like the doctor to address today?

While your pet is here with us today, would you like us to update:

	No	Yes
Nail Trim
Nail Dremel
Express Anal Glands
Microchip
Refill Heartworm and Flea Prevention
Refill Other Medication

Medication(s) to Refill
Best Contact Phone Number Today*

Area CodePhone Number

New Client Form

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete all the following:
Name/Owner*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Alternate Contact/Phone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Driver's License Number*
Do you want to add an additional contact?

YesNo
Contact #2 Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to owner
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Authorized to treat pet?

YesNo

Anesthetic and medical or surgical procedure(s) to be performed:*
Date and Time Last Fed:*
I, the undersigned owner or agent of the owner of the pet identified in this form, certify that I am eighteen years of age or over and authorize the veterinarian(s) at Thornwood Pet Care to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery, even in apparently healthy animal, including the risk of death. I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

·       The reasonable medical and/or surgical treatment options for my pet

·       Sufficient details of the procedures to understand what will be performed

·       How fully my pet will recover and how long it will take

·       The most common and serious complications

·       The length and type of follow-up care and home restraint required

·       The estimate of the fees for all services

·       Any necessary payment arrangements

While I accept that all procedures will be performed to the best of the abilities of the staff at Thornwood Pet Care, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to assume financial responsibility set forth in the treatment plan, and provide payment via cash, credit card, or check at the time my pet is discharged from the clinic.
Should unexpected life-saving emergency care be required and the clinic staff is unable to reach me, the staff:*

Has my permission to provide such treatment and I agree to pay for such services.Does not have my permission to provide such treatment.
In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours. If I desire that my pet have supervision when this facility is closed, I elect to:*

Pick up my pet and provide such care in my home, in which case I accept all risks of adverse effects.I will take to local emergency hospital before Thornwood will close (At least 1/2 hour before closing time).
Microchip and Registration*

I wish to microchip today for $45.99 (Does not Include Registration).No, I do not wish to microchip my pet today.I do not need this, my pet already has a microchip
I have read and understand the nature of the above procedures and give my consent to proceed. I authorize the use of anesthetics and other medications, as well as any additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent.
Typed Name as Signature*
Date*

MonthDayYear
Date

Consent for Dental Care

I, the undersigned owner or agent of the owner of the pet identified in this form, certify that I am eighteen years of age or over. I have been informed that my pet is in need of preventive or therapeutic dental care and hereby consent to the appropriate procedures described to me by staff veterinarians at Thornwood Pet Care. These procedures include but are not limited to the following:
1. Dental prophylaxes (routine teeth cleaning and polishing)
2. Extractions
3. Oral surgery to close gaps left by extractions
4. Root planing
5. Dental x-rays
6. Antibiotic gel implants
7. Oral biopsies/oral mass removals
I am aware that dental procedures for animals require the use of anesthesia to: 1) maximize visualization of the gums, teeth, and oral cavity, 2) minimize movement and discomfort, and 3) provide for the safety of the pet, doctors, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures and that I am encouraged to discuss any concerns I have about those risks with my attending veterinarian before these procedures are initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me, the staff at this practice has my permission to provide such treatment and I agree to pay for such care. I accept that veterinary medicine is not an exact science and that no guarantee of successful treatment has been made.

I have been informed that examinations under anesthesia often reveal abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other.

Otherwise, all questions and concerns I have about the recommended dental procedures have been answered to my satisfaction.

I understand that an estimate of the fees for the above dental care will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to assume financial responsibility for the balance of services rendered, and agree to provide payment on a cash, credit card or check basis at the time my pet is discharged.
I request that you (check one):*

Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, including any treatment to minimize any pain my pet may experience in the future from on-going dental disease.Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, unless the total cost exceeds $_____ OR if my pet has more than _____ teeth that the doctor deems to need extraction without a staff member contacting me first for authorization or information about other options (fill in $$ amount or number of extractions in "additional notes")Do not proceed with any procedure without attempting to contact me first.
Additional Notes ($$ authorized and/or number of extractions authorized)*
If I am unavailable by phone:*

I do give consent for extractions or procedures deemed necessary at the discretion of the attending doctor and agree to pay for all related fees.I do not give the attending doctor permission to proceed with extractions as clinically recommended.
I understand that I need to be reachable via phone at any time today in case a Thornwood Pet Care staff member calls regarding my pet's procedure.
Date and Time Last Fed:*
Typed Name as Signature*
Date*

MonthDayYear
Date

Should be Empty:

Medical History Questionnaire

New Client Form

New Pet Form