White Oak Veterinary Clinic

Scheduled Appointment Date*

MonthDayYear
Owner Name*

First NameLast Name
Co-Owner Name

First NameLast Name
Owner Address*
Owner Phone Number*
Co-Owner Phone Number
Owner Email Address*
Co-Owner Email Address
How would you prefer to receive reminders?*

EmailTextBoth Are Fine
Additional Emergency Contact. In the event that you cannot be reached during a pet emergency, please provide the name and contact information of someone who is authorized to make medical decisions on your behalf.

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
What is their relationship to you?
How did you hear about us?*

FacebookClient ReferralEmployee ReferralGoogleHeal Animal RescueGray Paws SanctuaryOther
If you were referred by a shelter, rescue, client, employee, or other source, please let us know who we can thank!*
Are you eligible for any of the following discounts? Please note: If more than one applies, only one discount can be applied per visit.

Senior Citizen (65+), 10% (must present valid driver's license)First Responder/Military, 20% (must present official ID)Animal Rescue Organization, 25% (must provide copy of current 501(c)(3) documentation)None of the Above
Do you have Pet Insurance? We partner with Trupanion and Pumpkin Pet Insurance and we can conveniently file claims for you right from our office. If no, we highly recommend exploring your options through Pawlicy Advisor. Visit www.pawlicy.com or email them at info@pawlicy.com to learn more.

YesNo
Do you have the Pet Desk App? PetDesk makes it easy to manage your pet’s care — including appointment reminders, refill requests, and direct communication with our clinic — all from your phone.

YesNo
Tell Us About Your Pet(s)
Pet #1
Pet Name*
Pet Birthdate or Age (If Known)
Color/Description*
Species*

DogCatRabbitFerretGuinea PigHamsterRatGerbilChinchillaMouseSkunk (Must provide permit)PigSheepGoatHedgehog (Must provide permit)
Breed*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Microchipped?*

YesNo
What is the reason for your visit?*
Please list any medical conditions your pet has:
Do you have another pet to add?

YesNo
Pet #2
Pet Name*
Pet Birthdate or Age (If Know)
Color/Description*
Species*

DogCatRabbitFerretGuinea PigHamsterRatGerbilChinchillaMouseSkunk (Must provide permit)PigSheepGoatHedgehog (Must provide permit)
Breed*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Microchipped*

YesNo
What is the reason for your visit?*
Please list any medical conditions your pet has:
Do you have another pet to add?*

YesNo
Pet #3
Pet Name*
Pet Birthdate or Age (If Know)
Color/Description*
Species*

DogCatRabbitFerretGuinea PigHamsterRatGerbilChinchillaMouseSkunk (Must provide permit)PigSheepGoatHedgehog (Must provide permit)
Breed*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Microchipped*

YesNo
Do you have an appointment for your pet? If yes, please provide your scheduled date and time.
What is the reason for your visit?*
Please list any medical conditions your pet has:
Do you have another pet to add?*

YesNo
Pet #4
Pet Name*
Pet Birthdate or Age (If Know)
Color/Description*
Species*

DogCatRabbitFerretGuinea PigHamsterRatGerbilChinchillaMouseSkunk (Must provide permit)PigSheepGoatHedgehog (Must provide permit)
Breed*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Microchipped*

YesNo
What is the reason for your visit?*
Please list any medical conditions your pet has:
If you have medical records for your pet(s), please upload them here. These records help us provide the best care for your pet(s) by ensuring we have accurate information about their health history, vaccinations, and any ongoing treatments.

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Payment & Cancellation Policy
Payment is due in full at the time services are rendered. If you have any questions or concerns about payment, please don’t hesitate to contact us before your appointment — we’re happy to help.

If you need to cancel or reschedule, please do so at least 48 hours in advance. Appointments not canceled within this timeframe will result in the forfeiture of your deposit. However, your deposit will be donated to our Angel Fund, which helps provide care for pets in need within our community.

We understand that emergencies happen. If your pet requires hospitalization or an emergency room visit, please have the emergency facility contact us directly so we can ensure your deposit is refunded. Likewise, if your pet sadly passes away, your deposit will be returned to you.

Thank you for your understanding, compassion, and support.
Social Media Release
White Oak Veterinary Clinic is proud to be active on Facebook, where we share heartwarming stories, helpful tips, and highlights from our amazing pet community.

By scheduling an appointment, you grant us permission to use your pet’s photo, video, or testimonial in our digital media — including social platforms and promotional materials — unless you request otherwise. This helps us celebrate the bond between pets and their families while showcasing the care we provide.

Participation is completely optional. If you prefer not to be featured, just let us know — we’ll always respect your wishes.
Thank You for Sharing Your Info!

We’re thrilled to have you and your pet as part of the White Oak Veterinary Clinic family! Your form has been received, and thanks to your timSubmite and effort, we’re all set to provide the best care possible at your upcoming visit. We can’t wait to meet you and your pet(s)!
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Tell Us About Your Pet(s)

Pet #1

Pet #2

Pet #3

Pet #4

Payment & Cancellation Policy

Social Media Release

Thank You for Sharing Your Info!