Spay/Neuter Client Intake Form
Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Will someone other than the owner be transporting the pet to / from the clinic?
*
Please Select
Yes
No
Name of person beside owner picking up / dropping off pet:
*
First Name
Last Name
Pet's Name:
*
Male or Female?
*
Please Select
Male
Female
Is the pet currently spayed or neutered?
*
Please Select
Yes
No
Age:
*
Approximate Weight:
*
Primary Color:
*
Secondary Color:
Cat or Dog?
*
Please Select
Cat
Dog
Breed of dog? (skip if pet is a cat)
Is the cat short, medium, or long haired? (skip if pet is a dog)
How long have you owned this pet?
*
Does the pet have a current rabies vaccine?
*
Please Select
Yes
No
*Current means either a 1 year or 3 year vaccine has been administered
If your pet does not have a current rabies, vaccine, can it have one?
*
Please Select
Yes
No
Does not apply
Does the pet have a current booster vaccine? DAPP for dogs or FVRCP for cats.
*
Please Select
Yes
No
*Current means vaccine was given within the last year
If your pet does not have a current booster vaccine, can it have one?
*
Please Select
Yes
No
Does not apply
When was the last time the pet was at the vet?
-
Month
-
Day
Year
Date
If your pet is currently on any medications, please list them & what they are for in the box below:
If your pet has any chronic health issues, please explain below:
Is your pet friendly to strangers?
*
Please Select
Yes
No
Does your dog wear a muzzle to the vet? (cat owners, please skip)
*
Please Select
Yes
No
N/A
Submit
Should be Empty: