New Client Form

Thank you for giving us the opportunity to care for your pet. We will be happy to answer any questions you have about your pet’s health. To ensure the best care possible, please take the time to fill out this form completely.

Name

First NameLast Name

Primary Mobile Number

Please enter a valid phone number.Format: (000) 000-0000.

Please enter your email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary owner information

First NameLast Name

Secondary Phone

Please enter a valid phone number.Format: (000) 000-0000.

Emergency

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred contact mode

How did you hear about us?

Name of referring client

In the future, I may request that my pet’s consolidated medical information or entire medical chart be transferred elsewhere (kennel, groomer, daycare, another veterinarian, other). I understand that the medical chart is a legal document that may also contain sensitive information about me and by requesting the transfer of my pet’s medical record, I am authorizing the release of its contents.

I hereby authorized the veterinarian to examine, prescribe for, and/or treat the animal(s) described on the following pages. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.

Signature of responsible party

Date

Name

Breed

Birthdate

Color

Sex

Previous Veterinarian

Purpose of last visit

Date of last visit

Date of last vaccines

Has your pet ever been sick after receiving vaccinations?

Is your pet on heartworm prevention?

Product Name

Date of last dose given

Is your pet on flea and tick prevention?

Product Name

Date of last dose given

Is your pet currently taking any long term medications?

If yes, please list

What foods are you currently feeding your pet? please list all sources, brands, and treats

Does your pet have a history of ear infections, skin infections, or hairloss?

Has your pet ever experienced a serious illness or disease?

Has your pet ever been diagnosed with any of the following conditions?

Date of treatment completion for heartworm disease

Diagnosis date of adrenal gland disease

Diagnosis date of diabetes

Diagnosis date of thyroid gland disease

Has your pet ever suffered from an injury requiring emergency care?

If yes, please explain

Please list any previous surgeries your pet has had, along with the date of procedure

Has your pet ever experienced a seizure?

Do you have any behavioral concerns (barking, inappropriate urination, etc.)?

Bone and joint health

General health questions

If allergies, please list

If vomiting - frequency

If diarrhea or constipation - frequency

Do you have pet insurance?

Would you like to discuss pet insurance plans?

Is there anything specific you would like us to know about your pet today, or have any concerns you would like to discuss?

New Client Form

Owner Information

Pet Health History

Previous Veterinarian