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New Client Application Form
This application, along with the Patient Registration Form, allows Dr. Rice to thoughtfully determine whether her personalized, in-home veterinary care is the right fit for your pet and family. Thank you for taking the time to complete it. We are honored to be considered for your pet's care.
Primary Name
*
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Do You Consent to Texts (Staff Communication and Appointment Reminders Only, no spam)
*
Yes
No, Email Only
Address (please include gate code if necessary)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please indicate where we should park when we arrive.
Primary Email
*
example@example.com
Would you like to add a second person to your account? If yes, please type their name and relationship to you below. You may also include their phone number and email.
*
You have thoroughly read and understand our "Practice Policies" as detailed on the website: https://drwoofsveterinarycare.com/practice-policies
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Yes
What is most important to you regarding overall medical care for your pet?
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How did you hear about us?
*
What services are you interested in through Dr. Woof's Veterinary Care?
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Exam/consultation
Vaccinations/vaccine titers
Evaluation of an illness or injury
Second opinion
Treatment or testing for valley fever
Kitten/puppy care
Senior/geriatric care
Pain management
Laser therapy/PEMF therapy
Anxiety/behavioral concerns
Nutrition/weight management
Hormone replacement therapy
Bloodwork or other laboratory tests
Referral for imaging, dental care, or surgery
Medications or refills
Other
To ensure the most thorough and attentive care, Dr. Rice uses a secure medical scribe to document your pet's visit in real time. This allows her to remain fully present while ensuring complete medical accuracy. All information is kept confidential. Do you consent to the use of a medical scribe during your pet's appointment?
Yes, I consent
No, I do not consent
By signing below you agree that you have thoroughly read and understand our "Practice Policies" as detailed on the website. You understand that we reserve the right to change any practice policy at any time: https://drwoofsveterinarycare.com/practice-policies
For their patient file, please upload a favorite photo of your pet.
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Pet's Name
*
Species
*
Please Select
Canine (dog)
Feline (cat)
Gender
*
Please Select
Male Intact
Male Neutered
Female Intact
Female Spayed
Breed
*
Color
*
Age/DOB (approximate if unknown)
*
How long have you had your pet?
*
Approximate Weight in Pounds
*
Is your pet microchipped? If so, please enter their microchip number.
Please upload your pet's medical records here or email them to drwoofsveterinarycare@gmail.com.
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Is your pet current on vaccinations? Please provide the dates they were/are due.
*
Has your pet ever had a vaccine reaction (mild or severe)? If yes, explain.
*
Has your pet ever traveled outside of Arizona? If yes, explain.
*
Please elaborate on the reason for your pet's visit. Does your pet have any pre-existing medical concerns of which we should be aware?
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What is your pet's diet (main food, treats, table food), quantities, and frequency?
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Is your pet currently taking any medications or supplements? If yes, please provide name, dosage, and frequency. This includes heartworm and flea/tick prevention.
*
Has your pet bitten anyone in the past? If yes, please explain.
*
How does your pet react to visitors to your home?
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How can we make this visit better for you and your pet? Is there anything special you would like us to know about your pet?
May we use your pet's name and photos/videos on our social media?
Yes
No
How did you hear about us?
Please Select
Friend/Family
Referring Veterinarian
Google
Facebook
Instagram
Nextdoor
Vehicle Decal
Other
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I understand that after I complete the Client Application and Patient Registration Forms, and if services are deemed to be an appropriate fit, I will be sent the Client Service Agreement and Consent to Treatment Form for review and signature.
I understand that after submitting my forms, the Practice Policies will be emailed to me for review, and a personalized service estimate will be sent separately for an electronic signature. My appointment will be confirmed once the signed estimate is received.
I understand that Dr. Woof's Veterinary Care does not offer emergency care, evening or weekend availability, and is closed major holidays.
I understand that if I am an acquaintance, friend, or family member of Dr. Rice, all policies, prices, and communicated boundaries apply to me, as for any other client of Dr. Woof's Veterinary Care.
By signing the box below and submitting this form, this verifies understanding and accurate completion of this form.
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