New Client Form

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.
Owner Information
Name*

First NameLast Name
Primary Mobile Number*
Please enter a valid phone number.
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.
Emergency

First NameLast Name
Phone Number
Please enter a valid phone number.
Preferred contact mode*

EmailCallText
How did you hear about us?*

Social MediaGoogle SearchDrove ByPersonal ReferralRescue/AKC
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.
Animal hospitals of the lowcountry would like your permission to use images taken of your pet on our website and social media platforms. If you do not consent to have your pet’s picture used, please click this box.
Signature of responsible party*

Clear
Date*

DayMonthYear
Pet Health History

Pet Information
Name*
Breed*
Birthdate*
Color*
Sex*
Previous Veterinarian
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?*

YesNo
Product Name
Date of last dose given
Is your pet on flea and tick prevention?*

YesNo
Product Name
Date of last dose given
Is your pet currently taking any long term medications?*

YesNo
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?*

Heartworm diseaseAdrenal gland diseaseDiabetesThyroid gland diseaseNoneOther
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?*

YesNo
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

Difficulty climbing up or down stairsStiffness or limpingDifficulty rising from sitting or resting positionDiagnosed with osteoarthritis, elbow or hip dysplasia, cruciate disease of the kneesLags behind on walks
General health questions

Bad breathAllergies (fleas, food, pollen, etc.)Increased drinking/urination/eatingUnexplained weight changeVomiting- frequency.Diarrhea or constipation- frequencyChange in activity level or association with family membersNew environment or environmental dynamics (new family member, sleeping arrangements, litter, work/play schedule)Coughing/sneezing/shortness of breathPanting even while restingConfusion or disorientationChange in sleep patterns (sleeps more or less, night vocalizing or pacing)
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? *
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New Client Form

Owner Information

Pet Health History

Previous Veterinarian