PetForward Urgent Care New Patient Welcome Form

Welcome to PetForward Urgent Care. We are glad to help you and your pet today!

Our aim is to provide high-quality up-to-date urgent pet healthcare by a caring and compassionate team that partners with you and your family veterinarian to improve the health/condition of your pet. We understand the bond you have and our team honors that. Please let us know how we can fulfill our mission to your family today.

We are an urgent veterinary care facility who truly CARES: Compassionate, Attentive, Respectful, Exceptional, Service-Oriented

Thank you for taking the time to fill out this form as completely and accurately as possible.

Are you the:

OwnerCo-OwnerResponsible Party

Did you just find this pet?

YesNo

Owner Information - Name:

Address:

City/State/Zip:

Primary Phone:

Email:

example@example.com

Co-Owner or Responsible Party Information - Name:

Address (if different):

City/State/Zip:

Primary Phone:

Email:

example@example.com

Preferred Contact Method:

How do you prefer to be addressed?

Other:

If other individuals are permitted to make medical and/or financial decisions for your pets, please list their name and contact information here:

How did you hear about us?

Pet's Name:

DOB or approximate age:

How long have you owned this pet?

DogCat

Other:

Breed:

Color:

Sex:

Male (intact)Male (neutered)Female (intact)Female (spayed)

Does your pet have a microchip?

YesNo

Name and phone of your primary veterinarian:

Do we have permission to contact them for past records or to send a report of medical visits with us?

YesNo

If your pet has been treated for an illness in the past year, please explain:

What is the primary concern you are having that brought you here today? Please explain with as much detail as you can. No detail is too small.

How many hours or day have the symptoms been occurring?

Are the symptoms:

Getting worse?Just not getting better?

Have you administered any home remedies?

YesNo

If yes, please list:

Has anything like this ever happened before?

YesNo

If yes, how was it treated and was it successful?

Please let us know what your pets primary diet is:

Is it grain-free?

Does your pet take any medications?

YesNoNot sure

If yes, please list the names of medications and when they were last administered:

Does your pet have any formal diagnosis from previous history? (Examples: Diabetes, Cushing's disease, Seizure disorder):

Please list any previous surgeries:

If your pet has ever had a reaction to a vaccine or medication, please explain:

Is your pet's rabies vaccine up-to-date?

YesNoNot sure

Are your pet's other veterinary-recommended vaccines up-to-date?

YesNoNot sure

Is your pet...

IndoorOutdoorIndoor/Outdoor

Do you have pet insurance?

YesNo

Which company?

Anything else we should know about your pet or your approach to your pet's healthcare?

THANK YOU for taking the time to complete this important information so we can best help your pet!

I assume full responsibility for all decisions regarding my pet's care, including medical consent and financial obligations. I understand that all charges incurred will be paid at the time of release, and that a deposit may be required for surgical treatment. I consent to the use of secure AI technology to assist in creating and maintaining accurate medical records for my pet.

Owner or Responsible Party Signature

Date

Printed Name

NEW PATIENT WELCOME FORM