New Patient Information

Welcome. We are happy that you have chosen us to care for your valuable pets.





Client Information:

Your First Name:
Your Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email Address:
  We can email exam report cards and important notices.
Spouse’s Name:
Spouse Cell:
Spouse Work:
Preferred Contact Method?:
*Cell Phone Service Provider:
How did you hear about us?
Other (please name):
Are you interested in our Pet Health Plans?


Financial Information

Credit Card:

 I have Pet Health Insurance

 I do not have Pet Health Insurance (Please tell me about it!)

 I hereby authorize the doctors and staff to diagnose, prescribe for, and treat the above described pet. I assume all responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time services are rendered. In the case of hospitalization, I will be required to leave a substantial deposit. The remaining balance must be paid in full at the time of discharge of the pet. I authorize photos and video to be taken of my pet’s care for training, website, and educational purposes.

Please present a valid drivers license or photo id at the time of check-in.

Pet Information

Pet Name:
Birth date/Approx age:
Type of Pet?
Breed:
Color:
Sex:
Neutered/Spayed:
Indoor/Outdoor:
Is your pet Microchipped?:
Where did you get your pet?
When did you get your pet?
Approx. age when acquired:
Are you 65 or older?
Are you a First Responder?
Past Veterinarian:
Would you like us to contact past vet for medical history?:
Approx. date of last veterinary examination:
Last vaccinations (date):
How many, and what type of pets do you own?
Dog(s):
Cat(s):
Bird(s):
Other (specify):
Kindly list any previous medical or surgical problems and current medications:
Is your pet current taking Heartworm Preventative?
Name of Meds.:
What flea and tick protection are you currently using on your pet(s)?
What brand of food is you pet currently eating?
How much do you feed daily?
Does your pet get any table scraps and how often?
Describe your pet’s temperament (personality)
Reason for visit:


The individuals listed below are authorized representatives to act on your behalf in cases dealing with the pet listed above. They are authorized to obtain medical information regarding your pet, to admit and pick up your pet from our facility, and give verbal and/or written authorization to perform medical services and procedures.
The individuals listed below are required to show photo identification when acting as your authorized representative.

  Name Relationship Contact Number
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I am not a robot.

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