Client / Patient Information Form

In order to expedite setting up your pet’s file return this basic information form. By sending us this information, in advance of your first visit, our receptionist will be able to have your pet’s file set up prior to your arrival.

Owners Information

Mailing Address

* Name: title/first/last:
* Name of spouse/partner:
* suite/number/street:
* city:
* postal code:

Contact numbers:

Telephone number: * home:
office:
cellular:
spouse:
Fax number:
E-mail address:

Employer/occupation:

Your preference for reminders/updates: Surface mail  E-mail

Have been to our hospital before? Yes No

How did you find us? Word of mouth Road/sidewalk visibility Yellow Pages Other

 

Pet(s) Information

* (1) Name:

* Species:

* Breed: Color:

Age:          Sex:   Female Spayed female Male Neutered male

Last vaccinations:

Flea/Heartworm prevention method:

Last fecal analysis/deworming:

Diet:

Nature: Outgoing/friendly  Shy/worried  Unruly/aggressive

Housed: Indoors  Outdoors

 

(2) Name:

Species:

Breed: Color:

Age:          Sex:   Female Spayed female Male Neutered male

Last vaccinations:

Flea/Heartworm prevention method:

Last fecal analysis/deworming:

Diet:

Nature: Outgoing/friendly  Shy/worried  Unruly/aggressive

Housed: Indoors  Outdoors

 

(3) Name:

Species:

Breed: Color:

Age:          Sex:   Female Spayed female Male Neutered male

Last vaccinations:

Flea/Heartworm prevention method:

Last fecal analysis/deworming:

Diet:

Nature: Outgoing/friendly  Shy/worried  Unruly/aggressive

Housed: Indoors  Outdoors

 

If you have additional pets please submit their data:

 

Medical History:

Previous veterinarian/clinic:

May we call ahead for your records? Yes No

Telephone number:

Specific concerns about your pet:

 

Payment Method:

Preferred method of payment: Cash MasterCard VISA Direct Debit

Do you carry Pet Medical Insurance? Yes No

If yes, which Pet Medical Plan do you subscribe to?

Thank you for sending in this information:)

Thank you.