New Patient Form
Please complete the following information to the best of your ability. This is a safe space, so please don't hesitate to be open and honest about your concerns, and we will work through them together. The more details you provide, the more time we can spend discussing and addressing your pet's specific needs.
Same-Day Consultation with Procedure Option
Have you previously spoken with Dr. Grellmann by phone about your pet’s health concerns prior to submitting this form?
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Yes
No
Have you previously called and tentatively scheduled a consultation appointment already?
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Yes
No
We offer the option for same-day consultations with procedures. These visits are typically day-long, with check-in at 8:00 or 8:30 a.m., and your pet is usually ready to go home in the mid to late afternoon. During your visit, you will have access to our office space and Wi-Fi. You’re welcome to stay on-site or come and go as needed, as long as you remain available by phone throughout the day. Please let us know if you would prefer this convenient same-day consultation and procedure option when scheduling your appointment.
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Same-Day Consultation with Procedure
Consultation Only
Client (Pet Owner) Information
Primary Contact's Name:
*
First Name
Last Name
Primary Contact's Pronoun(s):
He/Him
She/Her
They/Them
Relation to Patient:
Owner
Law Enforcement K9 Handler (Agency Representative)
Rescue/Shelter Foster or Care Coordinator
Primary Contact's Cell Phone Number:
*
Format: (000) 000-0000.
Primary Contact's Work Phone Number:
(Please enter if different from above.)
Format: (000) 000-0000.
Primary Contact's Home Phone Number:
(Please enter if different from above.)
Format: (000) 000-0000.
Primary Contact's Email:
*
example@example.com
Primary Contact's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Contact's Name:
First Name
Last Name
Secondary Contact's Pronouns:
He/Him
She/Her
They/Them
Secondary Contact's Cell Phone Number:
Format: (000) 000-0000.
Secondary Contact's Work Phone Number:
(Please enter if different from above.)
Format: (000) 000-0000.
Secondary Contact's Home Phone Number:
(Please enter if different from above.)
Format: (000) 000-0000.
Secondary Contact's Email:
example@example.com
Relation to Primary Contact:
Spouse / Partner
Co-Owner
Relative (e.g., Parent, Sibling, Grandparent)
Authorized Agent (e.g., Friend, Pet Sitter, Caretaker)
Law Enforcement K9 Handler (Agency Representative)
Rescue/Shelter Foster or Care Coordinator
Secondary Contact's Address: (If different from the Primary Contact's.)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Your Pet's General Information
Pet Name:
*
Species:
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Cat
Dog
Date of Birth:
*
(Best guess if unknown.)
Sex:
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Female
Female Spayed
Male
Male Neutered
Breed:
*
For non-purebred cats, please indicate it is a short, medium, or long-haired cat.
Primary Care Veterinary Clinic or Hospital
Practice Name
Primary Care Veterinarian
Veterinarian Name
Emergency Veterinarian or Referral Practice
Practice Name
Practice Location
City, State
If your pet was referred to us was a referral, please indicate the practice and veterinarian that reffered you here.
Practice Name
Veterinarian Name
How did you hear about us?
Referral by another veterinarian
Recommend by friend or family member
Google search
Other
Please provide the primary contact’s name. If you selected “Other", please specify.
Does your pet have insurance?
*
Yes.
No.
If you have insurance, who is your Provider?
If you have insurance, what is your pet's policy number?
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Your Pet's General Medical History
How has your pet’s general health been at home?
*
Rows
Normal
Increased
Decreased
Eating / Appetite
Drinking / Water Intake
Urination
Defecation
Have you observed any of these health issues at home?
*
Rows
Yes
No
Vomiting
Diarrhea
Coughing
Collapse
Exercise Intolerance
(e.g., gets tired easily on walks, heavy breathing
or needs to rest sooner than usual)
Itching / Skin Abnormalities
Does your pet have any known health conditions?
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None
Autoimmune Disease
Cancer
Diabetes Mellitus
Kidney Disease
Liver Disease
Respiratory Disease
Thyroid Disease
Seizures
Other / Not listed
Does your pet have any known allergies to MEDICATIONS?
*
Yes
No
If yes, please list which medications.
Does your pet have any known FOOD allergies?
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Yes
No
If yes, please list which ingredients.
Is your pet on a GRAIN-FREE pet food?
*
Yes
No
Is your pet on a PRESCRIPTION pet food?
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Yes
No
If yes, what type of prescription pet food is your pet currently on?
Please list the BRAND (e.g., Hill's, Royal Canin, Purina) and formula (for example, i/d or gastrointestinal).
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Your Pet's Medication History
Is your pet currently taking any STEROID MEDICATIONS?
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No
Prednisone or Prednisolone
Prednisolone / Trimeprazine (Temaril-P)
Methylprednisolone (Depo-Medrol; Medrol)
Other
Is your pet currently taking any non-steroidal anti-inflammatory drugs (NSAIDs)?
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No
Acetaminophen (Tylenol)
Carprofen (Novox; Rimadyl; Rovera; Vetprofen)
Deracoxib (Deramaxx)
Firocoxib (Previcox)
Ketoprofen (Ketofen; Anafen)
Meloxicam (Metacam; Meloxidyl)
Piroxicam (Feldene)
Robenacoxib (Onsior)
Other
Please list ANY other medications or supplements your pet is currently taking at home:
Please indicate your preferences for oral medications types. We will do our best to consider this when sending medications home in the future.
Rows
Yes
No
Liquid Medications
Pill Medications (Capsules and/or Tablets)
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Your Pet's Oral Health History
Please tell us about your pet's ORAL HEALTH and/or ANESTHESIA concern(s):
*
Have you observed any of these potential signs of dental disease at home?
*
Rows
Yes
No
Bad Breath
Bleeding Gums
Broken Teeth
Changes in Chewing Behavior
Decreased Activity (i.e., Slowing Down or Acting Old)
Decreased Socialization Behaviors
Discolored Teeth
Dropping Food While Eating
Facial Swelling
Nasal Discharge
Non-Healing or Chronic Facial Wounds
Oral Pain
Poor Grooming or Poor Coat Quality
Resists or Reluctant to Accpet Head Petting
Sneezing
When was your pet's last professional (with a veterinarian) dental cleaning performed?
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No professional dental cleaning performed yet
Within < 1 year ago
> 1 year ago
How concerned are you about tooth extractions?
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No Concerns with Extractions – Extract any teeth as needed, including proactively if it may minimize the need for future visits.
Tooth-Sparing Preferred – Please save as many teeth as possible. We are open to tooth-sparing procedures and understand that more frequent follow-up care may be needed to achieve the best outcomes. We also understand that extractions may sometimes be the better option when alternative treatments cannot provide predictably good results, and we consent to this when deemed necessary.
No Extractions (When Possible) – Please avoid extractions and prioritize tooth-sparing procedures whenever a reasonable medical alternative is available. We understand that more advanced or novel tooth-sparing treatments may be considered, and that these procedures may require regular follow-up care.
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Tooth brushing is the gold standard for oral hygiene, but not everyone has been doing or can do this kind of care at home. Please answer the following questions as appropriate.
*
Rows
Yes
No
Are you currently brushing your pet's teeth?
Are you able to brush your pet's teeth?
Are you interested in learning how to brush your pet's teeth?
If you have a DOG, what types of chew toys do you have at home for your pet? Please consider the following toy types: antlers, bones, hard plastic toys, nylon bones (e.g, Nylabone), rawhides, rope toys, rubber balls (e.g., Chuckit Balls), rubber chew toys (e.g., Kongs), and tennis balls.
Thank you for completing our "New Patient Form." We look forward to helping your pet and will reach out shortly to schedule your consultation.
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