Animal Magic Care New Client Form
Name
*
First Name
Last Name
Co-Owner (if applicable
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Animal Information
Please provide us some information about the animal you are bringing to Animal Magic Care.
Animal Name
*
Breed
*
Color(s)
*
Gender
*
Female
Male
Is your dog spayed or neutered?
*
Yes
No
Size (Please Note: Animal Magic Care is not accepting new clients that are over 100lbs at this time.)
*
Itty Bitty (less than 10 lbs)
Small (11 to 40 lbs)
Medium (41 to 70 lbs)
Large (71 to 100 lbs)
Birthdate or Approximate Age
*
Please describe what is currently going on with your dog. Pain? Limping? Trouble getting up? into car? onto furniture?
Please provide a list (number and species) of any other animals you have.
Veterinarian Information
Please provide us with some information about your current Veterinarian.
Primary Vet Clinic
*
Vet Clinic's website (if available)
Phone Number of Clinic (if available)
Phone Number of Clinic (if available)
Primary Veterinarian Name
*
When was your pet's last visit to the veterinarian?
What was the purpose of this visit?
Regular Wellness Appointment
Special Visit Due to Concern
Diet/Nutrition
Please tell us a little bit about your pet's current diet.
What type of food does your pet eat?
Kibble
Canned
Raw
Other
What is Brand Name of your pet's food?
Please list any supplements your pet takes.
Is your pet currently on any prescription medication?
Yes
No
Exercise/Fitness
Please tell us a little bit about your pet's regular exercise/fitness routine
What does your pet's typical exercise routine look like?
*
How many times per week does your pet complete the exercise routine you just described?
1 to 2 times a week
3 to 4 times a week
5 to 6 times a week
Everyday
Other
Final Section
How did you hear about us?
To help us serve you and your animal better, how would you categorize your first visit?
*
Maintenance: no rush
Feeling sore: sooner rather than later
Significant pain: visit is urgent
Acute trauma/issue; i.e. not walking, trouble going potty, screaming in pain: emergency
I agree to the Mandatory Disclosure/Informed Consent [find it here: https://subscribepage.io/animalmagiccare-disclosure]
*
Yes
No
I agree to the HIPPA form/Privacy Practices [find it here: https://subscribepage.io/animalmagiccare-hippa]
*
Yes
No
By typing your legal name below and submitting this form, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
*
Submit
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