Owner's Information

Primary Contact Name*

First

Last

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone*

Type

Email*

Communication Preference*

Text
Email
Phone Call

Please let us know your preferred form of communication for any time we need to reach out regarding your pet’s health, diagnostic testing or results.

What are your pronouns?*

Secondary Contact Information

Secondary Contact Name*

Secondary Contact Phone Number*

Type

Communication Preference*

Text
Email
Phone Call

Please let us know your preferred form of communication for any time we need to reach out regarding your pet’s health, diagnostic testing or results.

What are your pronouns?*

PET INFORMATION

Pet's Name*

Species*

Cat
Dog

Breed*

Color*

Date of Birth (Approximate)*

Sex*

PET QUESTIONNAIRE

Which of the following best describes your pet?*

Family Member
Child’s Pet
Backyard Pet

Where does your pet spend their time?*

Indoor only
Outdoor only
Both

Has your pet had any serious illnesses or surgeries?*

Does your pet have any allergies to vaccinations or medications?*

Is your pet on any special diets or medications?*

Would you like to be present during the treatment of your pet?*

Yes
No

Have you had your pet genetically tested?*

Yes, breed only
Yes, breed and health results
No

If you have genetic results, please upload them here

Drop files here or

Max. file size: 50 MB.

Do you use a Groomer or Boarding Kennel?*

Yes
No

Do you travel, hike, camp or hunt with your pet?*

Yes
No

Are you currently using any type of flea preventive?*

Yes
No

Does your pet have a microchip?*

Yes
No

It would be helpful to the treatment of your pet if we could obtain his/her previous medical records. May we contact your previous Veterinarian to obtain them?*

Yes
No

If you have a copy of your pet's previous records, please upload them here

Drop files here or

Max. file size: 50 MB.

If you do not have access to your pet’s prior records, we are happy to contact your prior vet’s office on your behalf to request records.

Do you consent to this communication?*

Yes
No

If no, please contact the prior vet at least 48 hours before your first appointment with us and request they send all of your pet’s medical records and vaccine history for your pet to our email at [email protected].

If yes, please provide the following information.

Name of your pet’s prior vet location(s)
Phone number of prior vet location(s)
Your specific pet’s name, owner’s first and last name, as well as owner’s phone number if it is different than what is provided in this form. (For example, if you have changed your pet’s name since adoption or if prior owners handled vet visits and the office files would be under a different name than your own.)
If all the owner contact information and pet’s name is the same at the prior vet as it is provided in this form, please note this by entering “Same Information” below.

Write your response for above here*

The health status of your human family may effect the medical recommendations for your pet's preventative healthcare. Is anyone in your household immune compromised (Cancer, Diabetes, Hepatitis or HIV positive)?*

Yes
No

Do you consent to photos of your pet being utilized in hospital promotions and on Social Media?*

Yes
No

Client Information Form

Owner's Information

Secondary Contact Information

PET INFORMATION

PET QUESTIONNAIRE

Get in touch

(215) 721-6989

Business Hours