New Client Form
Client Information
First Name
*
Last Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
*
Pet Information
Pet Name
*
Pet Age
*
Species
*
Breed
*
Color
*
Sex
*
Where did you get your puppy/kitten?
*
Has the pet been spayed/neutered?
*
Yes
No
Does the pet have a microchip?
*
Yes
No
If yes, what is the chip number?
*
Has the pet been seen at another veterinary hospital?
*
Yes
No
If yes, who can we contact to get records?
*
What is the current diet?
*
Is the pet on flea, tick and heartworm preventative control?
*
Yes
No
If yes, what brand and when was the last dose?
*
Any recent coughing, sneezing, vomiting or diarrhea?
*
Yes
No
If yes, when did it start?
*
Any new lumps or bumps?
*
Yes
No
If yes, please explain.
*
Any changes to appetite or thirst?
*
Yes
No
If yes, when did it start?
*
Does the pet go to boarding, grooming or daycare?
*
Yes
No
Does the pet go hiking or is the pet exposed to deer/wildlife?
*
Yes
No
Is the pet on any regular medications?
*
Yes
No
If yes, what are they? Refills?
*
Do you have any concerns that need to be addressed during the appointment?
*
Dictation Consent
Our hospital utilizes ScribbleVet, a dictation software that records your pet's visit and allows for improved medical documentation. We need your consent to proceed with recording this visit. By signing below, you acknowledge that your pet's visit may be recorded. You grant us permission to utilize these records to document your pet's visit. You agree that you are at least eighteen years old, and you understand and accept the terms of this consent.
*
I approve the use of ScribbleVet during my pet's visits
I decline the use of ScribbleVet during my pet's visits
Owner Signature
*
Deposits
A $40.00 deposit is required for first-time clients.
Please use this link to submit payment
.
I acknowledge there is a $40 required deposit for first-time clients, please initial below
*
Please verify that you are human
*
Submit
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