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New Client Registration Form
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.
Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
Owner's Name
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Day-Time Phone
*
Evening Phone
Mobile Phone
*
Email
*
Enter Email
Confirm Email
Co-owner's Name & Contact #
Name
First
Last
Phone
How did you find out about our practice?
*
Personal Referral
Internet Search / Website
Social Media
Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Are you ready to schedule an appointment?
*
Yes
No
What is the reason for the appointment?
*
Please list preferred dates and times for appointments.
*
Please use this area to give us any other relevant information about yourself or your family
I understand payment is due in full at the time services are rendered. Any delay in payment will incur a daily fee for each subsequent day that payment is late.
*
Yes, I understand
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Rabbit/Guinea Pig
Ferret
Reptile
Other
If "Other" species, please specify.
Breed
*
Color
Date of Birth or Age
*
Special Identification (tattoo, microchip, etc.)
Sex
*
Neutered Male
Spayed Female
Male
Female
Unknown
Previous Veterinary Practice
*
May we contact them for previous history?
*
Yes
No
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Fear Free Questions
We want to make your pet’s veterinary experience as enjoyable and as stress-free as possible.
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end.
Select All
Getting in their carrier or the car
Entering the veterinary hospital
Being approached by veterinary staff
Getting on the scale for a weight
Being put up on the table for examination
Loud voices during examination
Having a rectal temperature taken
Having direct eye contact with the technician and/or veterinarian
The use of instruments such as the stethoscope or otoscope (to look in the ears)
How would you describe your pet around other animals and people?
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) if so, how did your pet react?
What are your pet’s favorite treats? (Please bring some to your next visit with us):
Does your pet like to play with toys? If so, what kinds?
Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did your experience?
Anything else you would like us to know?
Would you like to add an additional pet?
Yes
No
Second Pet's Name
*
Second Pet's Species
*
Dog
Cat
Rabbit/Guinea Pig
Ferret
Reptile
Other
If "Other" species, please specify.
*
Second Pet's Breed
*
Second Pet's Color
Second Pet's Date of Birth or Age
*
Second Pet's Special Identification (tattoo, microchip, etc.)
Second Pet's Sex
*
Neutered Male
Spayed Female
Male
Female
Unknown
Second Pet's Previous Veterinary Practice
*
May we contact them for previous history?
*
Yes
No
Is your second pet on any medication or supplement?
Yes
No
If Yes, please list second pet's medication or supplement
What food does your second pet eat?
Does your second pet have allergies or drug reactions?
Yes
No
If Yes, please list second pet's allergies and reactions
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Fear Free Questions
We want to make your pet’s veterinary experience as enjoyable and as stress-free as possible.
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end.
Select All
Getting in their carrier or the car
Entering the veterinary hospital
Being approached by veterinary staff
Getting on the scale for a weight
Being put up on the table for examination
Loud voices during examination
Having a rectal temperature taken
Having direct eye contact with the technician and/or veterinarian
The use of instruments such as the stethoscope or otoscope (to look in the ears)
How would you describe your second pet around other animals and people?
Does your second pet have any sensitive areas that s/he does not like to have touched by you or others?
Are there any procedures your second pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) if so, how did your pet react?
What are your second pet’s favorite treats? (Please bring some to your next visit to our hospital):
Does your second pet like to play with toys? If so, what kinds?
Has your second pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did your experience?
Anything else you would like us to know about your second pet?
Would you like to add an additional pet?
Yes
No
Third Pet's Name
*
Third Pet's Species
*
Dog
Cat
Rabbit
Ferret
Reptile
Other
If "Other" species, please specify.
*
Third Pet's Breed
*
Third Pet's Color
Third Pet's Date of Birth or Age
*
Third Pet's Special Identification (tattoo, microchip, etc.)
Third Pet's Sex
*
Neutered Male
Spayed Female
Male
Female
Unknown
Third Pet's Previous Veterinary Practice
*
May we contact them for previous history?
*
(Please enter "Yes" or "No")
If Yes, please list the third pet's medication or supplement
What food does your third pet eat?
Does your third pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Fear Free Questions
We want to make your pet’s veterinary experience as enjoyable and as stress-free as possible.
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end.
Select All
Getting in their carrier or the car
Entering the veterinary hospital
Being approached by veterinary staff
Getting on the scale for a weight
Being put up on the table for examination
Loud voices during examination
Having a rectal temperature taken
Having direct eye contact with the technician and/or veterinarian
The use of instruments such as the stethoscope or otoscope (to look in the ears)
How would you describe your third pet around other animals and people?
Does your third pet have any sensitive areas that s/he does not like to have touched by you or others?
Are there any procedures your third pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) if so, how did your pet react?
What are your third pet’s favorite treats? (Please bring some to your next visit to our hospital):
Does your third pet like to play with toys? If so, what kinds?
Has your third pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did your experience?
Anything else you would like us to know about your third pet?
Home
New Clients
About Us
Our Team
Services
Wellness and Vaccinations
Preventive Services
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Exotic Pet Medicine and Surgery
In-home Euthanasia
Pet Health
How-To Videos
Pet Food Recalls
Product Recalls
Contact Us
Request an Appointment
New Client Form
Online Pharmacy
