• New Patient (Current Client) Form

    Shady Brook Animal Hospital

  • Please enter your information so we can locate your account.

  • Format: (000) 000-0000.

  • PATIENT INFORMATION

  • Species*
  • Sex:*
  • Neutered/Spayed?*

  • DIET AND ENVIRONMENT

  • Does {patientName} consume table food?
  • Is {patientName} primarily indoor or outdoor?
  • Do you have {patientName} groomed or boarded outside of your home?
  • Do you travel outside of Texas with {patientName}?
  • Are there any other pets in the household?
  • Are there any small children in the household?

  • HEALTH HISTORY

  • Has {patientName} had any prior illnesses, accidents, or surgeries?
  • Has {patientName} ever shown aggression or fearfulness around strangers?*
  • Does {patientName} take any medications or supplements?*
  • Is {patientName} on any heartworm or flea/tick preventatives?*
  • Does {patientName} have any known allergies?*
  • Has {patientName} ever had any reactions to vaccines?*
  • Are there any topics you would like more information on or would like to discuss with the doctor? (Select all that apply)

  • AUTHORIZATIONS, PREVIOUS RECORDS, AND PATIENT PHOTO

  • Do we have your permission to share {patientName}'s image and story on our social media, website, and other forms of related media?*
  • Date*
     - -
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  • Pet Photo:

    Please feel free to upload your favorite picture of {patientName}, and we will update {patientName}'s hospital chart to include their photo.

    *This photo will not be used for any other purpose than the patient's hospital chart. Uploading a photo does not give the hospital permission to use this photo on any social media accounts.

  • Should be Empty: