New Client & Patient
Please fill out the registration form below in order to create your account with us. An account is REQUIRED in order to provide an estimate for services or make an appointment. Questions with a red asterisk are REQUIRED to be filled out. Questions without a red asterisk are optional, but helpful for us to provide an accurate estimate for your appointment.
Owner's Full Name
*
First Name
Last Name
Owner's Email Address
*
example@example.com
Owner's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Owner's Address (House number and street)
*
City
*
Zip Code
*
Are there special directions to help us find you? Do we need a gate code or unit number?
*
Co-owner's Name (if applicable)
Co-owner's Number (if applicable)
Pet's Name
*
Species
*
Canine
Feline
Breed(s)
*
What color is your pet?
*
Date of Birth of Pet
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please estimated age if date of birth is unknown
Sex of Pet
*
Male
Female
Is your pet spayed or neutered?
*
No
Yes
Unsure
Does your pet have a microchip?
*
Yes, please include the number below
No
I don't know
No, but I would like one placed today
My pet has a microchip, but I do not know the number
Microchip Number
Select Services Wanted
*
Wellness exam and/or vaccines
Exam for illness or medical concerns
Check skin or ears (dermatology)
Fertility consult (male or female)
Artificial Insemination
Pregnancy Ultrasound
Semen collection and shipping
Progesterone testing
Litter exam, puppies or kittens
OFAs testing or PennHIP testing
Other
Specific services requested (i.e. blood work, rabies vaccine, nail trim, ear cleaning)
What concerns do you have about your pet? What goal do you have for this appt?
When are you looking to book this appointment? Please provide a couple of days that would work with your schedule.
*
Which veterinarian has cared for your pet before us? PLEASE HAVE THEM SEND RECORDS TO VIVAVETSERVICES@GMAIL.COM
Is your pet due for vaccines? If yes, which ones?
How did you hear about us?
Social media, facebook or instagram
Referral from a friend, family, or acquaintance
Google or other search engine
Other
What is the name of person who referred you? We give clients who successfully refer a new client to us $10 off their next housecall!
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