New Patient Information Sheet

Patient Information

Pet's Name

Sex

Male
Female

Species

Dog
Cat
Other

Neutered or Spayed?

Yes
No

Date of Birth

Breed

Color

Reason for today's visit

Does your pet have/has your pet had... (if yes, please describe in the space provided):

A microchip or tattoo?

Yes
No

If yes, please describe.

Any previous surgeries?

Yes
No

If yes, please describe.

Any known allergies?

Yes
No

If yes, please describe.

Any known illnesses?

Yes
No

If yes, please describe.

Any idiosyncrasies?

Yes
No

(i.e. bites, scratches, responds to more or less restraint, more calm with or without owner?)

If yes, please describe.

Any pet insurance?

Yes
No

If yes, please describe.

Name of previous veterinarian:

Last Visit?

Phone

Client Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email

Employer

Preferred method of contact

Email
Phone Call
Text

Preferred contact number:

Home
Work
Cell

Co-owner contact information:

Emergency contact information (if different from co-owner)

Payment Policy

Payment is expect for all services rendered at the time of your visit. We accept cash, Amex, Visa, MasterCard, Care Credit and personal checks. A deposit and an agree upon repayment plan will be required for extensive medical or surgical treatment. I verify that all the information provided above is accurate.

Signature

Date

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 12:30pm
Sunday	Closed

Contact Us

New Patient Information Sheet