Form
New Client/Patient Form
What we need to know before your first appointment
Name
First Name
Last Name
Email Address (Please note this is where all lab results and vaccination records will be sent)
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Our truck is large, where is the preferred place for us to park when we arrive?
Is there a gate code for entry? If so provide here.
Given we are mobile the fastest response time will be with text or email. When we can, we will also make phone calls but will take longer for follow up. Let us know here your preferred method of contact.
Text
Email
Phone Call
Pet Information
Pet's Name
Species
Canine
Feline
Breed/Color
Estimated Age or Birthday
Spay/Neuter Status
Please Select
Female Intact
Male Intact
Male Neutered
Female Spayed
Pet#2 Name
Species
Canine
Feline
Breed/Color
Estimated Age/Birthday
Spay/Neuter Status
Please Select
Female Intact
Male Intact
Male Neutered
Female Spayed
Pet#3 Name
Species
Canine
Feline
Breed/Color
Estimated Age/Birthday
Spay/Neuter Status
Please Select
Female Intact
Male Intact
Male Neutered
Female Spayed
What are we seeing your pets for? What concerns do you have? Be as detailed as possible so that we may come prepared.
Is there someone we can reach out to for previous records, this is very important prior to first appointment so that we may review and prepare with a full knowledge of your pets previous medical history.
How does you pet usually act at a veterinary office, do they often react fearful or have any specific aversion to any types of procedures, or any areas of sensitivity? (nail trims, blood draws, touching feet or hip areas for example)
How does your pet react to visitors in your home? Anything we should know when preparing for the visit?
Is your pet fearful or aggressive, should additional time be planned for a fear free approach?
yes
no
Is you pet on heartworm and/or flea/tick control? If so what kind? Will you need more at this up coming visit?
What other medications is your pet on? (provide as much detail such as type, amount and frequency)Will you need refills?
List all diets and foods that your pet is eating and if there are any dietary sensitivities we should know about(as we do like to bring treats)
Vance Veterinary maintains an Internet (social media, website, etc.) presence for purposes including marketing and client education. Part of this presence includes photographs of our practice and its daily workings. Therefore, we may be interested in using images of your pet(s) and/or family as part of the effort to maintain, expand, and educate the public about our business and services, as well as include clients in every aspect of our practice. Please let us know how we may use/post photographs of your pet(s) and/or family: *
Vance Veterinary has my permission to use or post photographs of my pet(s) and/or self/family
Vance Veterinary may NOT use or post photographs of my pet(s) and/or family
Let us know who we should thank for your referral or on what platform you came to know about us.
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