Heal New Patient Form

New Patient Form
Owner Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
By checking the box below, you agree to receive SMS messages from Heal Cancer Care for Pets related to conversation SMS messages. You may reply STOP to opt out at any time. Reply HELP to 206.888.HEAL (4325) for assistance. Messages and data rates may apply. Message frequency will vary. Learn more in our Privacy Policy and SMS Terms & Conditions.
I agree
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse/Secondary Owner Name

First NameLast Name
Secondary Email
example@example.com
Secondary Phone
Please enter a valid phone number.
Patient Information
Pet Name*
Sex*

MaleFemale
Spayed/Neutered?*

YesNo
Date of Birth/Estimated Age*
Species*

DogCat
Breed*
Name of Primary Veterinarian*
Name of Primary Care Clinic*
Presenting Concerns & Medical Background
What brings your pet to Heal Cancer Care today?*
When did you first notice signs or symptoms?*
Please describe any current symptoms*

Lump or massWeight lossVomiting/nauseaLethargyPain or discomfortOther
Has your pet been diagnosed with cancer before?*

YesNo
Please describe the type of cancer and date of diagnosis*
Current medical conditions and/or medications*
Any known allergies?*

YesNo
Please describe your pet's allergies*
Has your pet had any recent diagnostic tests (bloodwork, X-ray, biopsy)?*

YesNo
Has your pet received any cancer treatment before?*

YesNo
Please upload any medical records or lab results

Cancelof
Additional Information
How did you hear about us?*

Veterinary ReferralFriend ReferralSocial MediaWeb SearchOther
Is there anything else you'd like us to know?*
Authorization
I authorize Heal Cancer Care for Pets to obtain and review my pet’s medical history.*

I agree
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

New Patient Form

Owner Information

Patient Information

Presenting Concerns & Medical Background

Additional Information

Authorization