New Patient Registration

New Patient Registration

Please complete the following information to allow us to better serve you and your pet. We are honored to serve as your family's veterinarian and look forward to working with you!
Client Information (Your Info)
Primary Contact*

First NameLast Name
Primary Contact Phone Number*
Please enter a valid phone number.
Phone type:*
Primary Contact Email*
example@example.com
Employer/Occupation*
Primary Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary/Emergency Contact*

First NameLast Name
Secondary/Emergency Contact Phone*
Please enter a valid phone number.
Secondary/Emergency Contact Email
example@example.com
What is the Secondary/Emergency Contact's relationship with the Primary Contact?*
Have you been to our clinic before?*

YesNo
How did you hear about us?*

LocationInternet/GoogleSocial MediaFamily/FriendOther
Who can we thank for referring you to our clinic?*

Patient Information

Tell us about your pets!
How many pets are you wanting to register today?*
Your Pet's Name*
First Pet's Name*
Second Pet's Name*
Third Pet's Name*
Fourth Pet's Name*

Permissions and Acknowledgments

Almost done! We just need to go through a few more important details.
I give permission for Candlewood Veterinary Clinic to use my pet(s) image and name on social media sites and the clinic's website:*

YesNo
I give Candlewood Veterinary Clinic the authority to request records for my pet(s) from their previous veterinary hospitals.*

YesNo
Food Allergy Exposure Acknowledgment:

Candlewood Veterinary Clinic staff practice Fear Free veterinary medicine. Peanut butter, cheese, and other treats may be used as part of your pet's Fear Free experience at the clinic.

I understand it is my responsibility to inform the team at Candlewood Veterinary Clinic if there is a food allergy in my household (i.e. peanut allergy) that would require the veterinary team to avoid feeding specific food or treats.
Initials*
Payment Policy Acknowledgment:

I understand that payment is due in full at the time of service.
Initials*
Authorization:

I, the undersigned owner or agent of the owner, certify that I am 18 years of age or older and do hereby authorize Candlewood Veterinary Clinic veterinarians and staff to examine my pet(s) and administer treatment as considered necessary for my pet's condition.

A treatment plan with care options will be discussed with me prior to any diagnostic treatments. In life-threatening situations, stabilizing care may be instituted immediately.
Signature

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	Yes	No	If yes, please describe.
Has your pet had any REACTION to previous vaccines?
Does your pet have any allergies?
Is your on any medications or supplements?
Does your pet have any ongoing medical concerns?
Is your pet currently on FLEA AND TICK prevention? If yes, which prevention?
Is your pet currently on HEARTWORM prevention? If yes, which prevention?
Is your pet microchipped? If yes, what is their microchip number?
Are there other pets in the household?

	Yes	No	If yes, please describe.
Has your pet had any REACTION to previous vaccines?
Does your pet have any allergies?
Is your on any medications or supplements?
Does your pet have any ongoing medical concerns?
Is your pet currently on FLEA AND TICK prevention? If yes, which prevention?
Is your pet currently on HEARTWORM prevention? If yes, which prevention?
Is your pet microchipped? If yes, what is their microchip number?
Are there other pets in the household?

	Yes	No	If yes, please describe.
Has your pet had any REACTION to previous vaccines?
Does your pet have any allergies?
Is your on any medications or supplements?
Does your pet have any ongoing medical concerns?
Is your pet currently on FLEA AND TICK prevention? If yes, which prevention?
Is your pet currently on HEARTWORM prevention? If yes, which prevention?
Is your pet microchipped? If yes, what is their microchip number?
Are there other pets in the household?

	Yes	No	If yes, please describe.
Has your pet had any REACTION to previous vaccines?
Does your pet have any allergies?
Is your on any medications or supplements?
Does your pet have any ongoing medical concerns?
Is your pet currently on FLEA AND TICK prevention? If yes, which prevention?
Is your pet currently on HEARTWORM prevention? If yes, which prevention?
Is your pet microchipped? If yes, what is their microchip number?
Are there other pets in the household?

New Patient Registration

Client Information (Your Info)

Patient Information

Medical History & Information

Medical History for
{yourPets76}

Please answer the following questions for {yourPets76}.

Medical History for
{firstPets80}

Please answer the following questions for {firstPets80}.

Medical History & Information

Medical History for
{secondPets}

Please answer the following questions for {secondPets}.

Medical History & Information

Medical History for
{thirdPets}

Please answer the following questions for {thirdPets}.

Medical History & Information

Medical History for
{fourthPets}

Please answer the following questions for {fourthPets}.

Permissions and Acknowledgments

New Patient Registration

Client Information (Your Info)

Patient Information

Medical History & Information

Medical History for{yourPets76}

**Please answer the following questions for {yourPets76}.**

Medical History for{firstPets80}

**Please answer the following questions for {firstPets80}.**

Medical History & Information

Medical History for{secondPets}

**Please answer the following questions for {secondPets}.**

Medical History & Information

Medical History for{thirdPets}

**Please answer the following questions for {thirdPets}.**

Medical History & Information

Medical History for{fourthPets}

**Please answer the following questions for {fourthPets}.**

Permissions and Acknowledgments

Medical History for
{yourPets76}

Please answer the following questions for {yourPets76}.

Medical History for
{firstPets80}

Please answer the following questions for {firstPets80}.

Medical History for
{secondPets}

Please answer the following questions for {secondPets}.

Medical History for
{thirdPets}

Please answer the following questions for {thirdPets}.

Medical History for
{fourthPets}

Please answer the following questions for {fourthPets}.