Welcome To Our Clinic
New Client Information Form
Client Name (Primary)
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home Phone Number
*
Do not put your cell phone number. If you do not have a home phone, please enter all 000-000-0000
Cell Phone Number (please enter all 0 if no cell phone)
*
Cell phone numbers only please.
Work Phone Number
If you do not have a work number you'd wish to share, please type all 000-000-0000
Client Name (Secondary, if applicable)
First Name
Last Name
Client Phone Number (secondary)
Preferred number to reach if the primary person listed is not available.
How did you hear about us?
*
Website
Facebook
Referral
Other
Date of appointment:
Do you give us permission to post photos of your pets on social media?
Yes
No
Yes. I want to be asked first though
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Pet Information
Please fill out one section for each pet.
Pet Name
*
Birthdate
*
-
Month
-
Day
Year
Date Picker Icon
Species
*
Canine (Dog)
Feline (Cat)
Other
Breed
*
Color
*
Sex
*
Male
Female
Unknown
Is your pet altered? (spayed or neutered)
Spayed (females)
Neutered (males)
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Patient Intake Form
Please answer the following questions to the nest of your knowledge. This form must be completed prior to your appointment.
Phone Number
Please enter the phone number we can call while you are here for your appointment.
Vehicle Description
To find you when coming to get your pet out of your car in the parking lot.
Patient Name
Scheduled Appointment Date
-
Month
-
Day
Year
Date
Scheduled Appointment Time
Hour Minutes
AM
PM
AM/PM Option
Primary Reason for Visit/Concerns. If any concerns, please state how long the issue has been going on for.
Please be as detailed as possible
Have there been any changes to the following?
Appetite
Drinking
Urination
Coughing
Sneezing
Vomiting
Diarrhea
Medications
None of the above
Please explain any abnormalities or changes you listed above.
What are you feeding your pet? Please list the names an types (wet, dry) of food and treats given to your pet throughout the day.
List all medications and supplements your pet is currently on, including doses.
This does include monthly preventative medication such as Heartgard or Nexgard
Are there any prior illnesses or injuries that we are not aware of?
Does your pet visit any of the following?
Boarding or Day Care
Groomer
Dog Parks
None of the above
Where does your pet spend most of his/her time?
Indoors
Outdoors
Equal time Indoor and Outdoor
Do you have other pets at home? If yes, please list what kind below.
Is your pet current on his/her Rabies vaccination?
Yes
No
Unknown
Please list where your pet has been seen at before so we may call for previous medical records.
Are you or anyone in your household experiencing COVID like symptoms?
Yes
No
Have you been exposed to anyone with COVID?
Yes
No
Is there anything else we should know about your visit today?
Submit
Should be Empty: