Tell us about you |
Name
|
Spouse/Other
|
|
|
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E-Mail Address :
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I prefer to be contacted by
Phone
Text
Email
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Please do not call before or after (time of day)
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How did you hear about us?
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If a referral, whom may we thank?
|
When discussing my pet’s care and considering treatment options, I prefer to
have things explained to me in detail
just get the basics explained
get in, get out, get on with my day
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Tell us about your pet |
Pet's Name
|
Species (Dog, Cat, etc.)
Dog
Cat
Other
|
If other, please describe
|
Breed
|
Age/Birthday
|
Color(s)
|
Sex
M
F
Unsure
|
Spayed/Neutered?
Yes
No
Unsure
|
Microchip #
|
What percentage of time does your pet spend inside? (%)
|
What percentage of time does your pet spend inside? (%)
|
My pet is:
more important to me than my kids/spouse
part of the family
just a pet
|
Other Pets in Household
|
Your Pet's Health History |
What type of food/treats does your pet normally eat?
Dry
Canned
Both
|
What Brand(s)?
|
Vaccination History (Date and Type of Last Vaccination, if known)
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Has your pet ever had any major illnesses/injuries/surgeries?
Yes
No
|
If yes, please describe
|
Does your pet have any allergies? (including foods, medications, vaccinations, environmental things like plants, pollen, etc.)
Yes
No
|
If yes, please describe:
|
Is your pet currently on any medications? (including flea/tick/heartworm/intestinal parasite preventatives, vitamins, herbal remedies, joint supplements, etc.) Please describe:
|
HAVE YOU NOTICED ANY? |
Please check all that apply to your pet or that you want to talk with us about.
Behavioral Problems/Changes
Bad Breath/Dental Problems
Breathing Problems
Coughing/Gagging
Changes in Appetite/Weight
Changes in Drinking/Urination
Depression/Lethargy
Diarrhea/Stool Changes
Falling Down/Balance Problems
Head Shaking
Limping/Trouble Rising
New And/Or Growing Lumps
Scratching/Biting/Rubbing
Scooting
Vomiting
Weakness/Collapse
Other-Describe below
|
YOUR PET’S TYPICAL VETERINARY EXPERIENCE |
When it’s time for a visit to the vet, my pet…
Becomes aggressive/bites/scratches
Becomes terrified, pees, poops, hides
Is, overall, reasonably tolerant of the whole ordeal
Looks forward to it like a kid at Christmas
|
While at the vet’s office, my pet…
Becomes aggressive/bites/scratches
Is, overall, reasonably tolerant of the whole ordeal
Becomes terrified, pees, poops, hides
Looks forward to it like a kid at Christmas
|
If your responses to either of the above questions are in the column on the left, PLEASE talk to us BEFORE your visit about how we can reduce your pet’s fear, anxiety and stress and improve the overall experience for everyone! |
AUTHORIZATION |
I, HEREBY STATE, THAT I AM THE LEGAL OWNER OR AGENT OF THE ABOVE DESCRIBED PET AND AS SUCH, AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT THAT PET. I UNDERSTAND THAT I ASSUME RESPONSIBILITY AND AGREE TO PAY FOR ALL CHARGES INCURRED IN THE CARE AND TREATMENT OF THIS PET AND THAT PAYMENT IS EXPECTED AT TIME SERVICES ARE RENDERED UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.
I further understand that it is always my right to request a detailed, written estimate of charges, PRIOR to the commencement of any anticipated or recommended treatment. |
Agreement
I Agree
I Disagree
|
My preferred method of payment is:
Cash
Check
Mastercard/Visa
Discover
Care Credit
Other
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I have pet insurance for this patient. If yes, what company?
|
I am interested in learning more about Care Credit
Yes
No
|
I am interested in learning more about Pet Insurance
Yes
No
|
Processing ....
GO GREEN! GO GLEN!
