Client Form Client and Patient Information Form Owner Contact Information First Name * Last Name * Email * Phone * Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Employer Work Phone Spouse or Co-Owner Contact Information Co-Owner's First Name Co-Owner's Last Name Co-Owner's Email Co-Owner's Phone Co-Owner's Employer Co-Owner's Work Phone Please tell us how you learned about us: Friend/NeighborPhone BookStreet SignRescueEventFlyer/BrochureInternetOther FINANCIAL POLICY: I/We assume responsibility for all charges incurred in the care of our pet and in the future. I/We also understand that these charges will be paid in full at the time of visit. We accept cash, check, Discover, Visa, and Mastercard. Any questions, feel free to discuss prior to the services. Owner / Responsible Party Clear Alternative Authorization Clear Pet Information Pet's Name * Pet Species * DogCatOther Pet's Breed Pet's Color Sex * MaleFemaleI don't know Age (if known) Birth Date (if known) Neutered/Spayed * YesNoI don't know Veterinary hospital where past records may be obtained Does your pet have an I.D. Microchip? YesNoI don't know Temperament: Outgoing/SocialNeutralShyAggressive Is your pet on heartworm prevention? YesNo Is your pet on flea/tick prevention? YesNo Does your pet have allergies? YesNo Has your pet ever had a dental cleaning? YesNo Prior illness or surgery Please list other pets in household (name and species) List supplements, medications, and pet's diet (brand, wet/dry, snacks) Reason for today's visit Assessing Your Pet's Health Risk How many hours a day does your pet spend outdoors? Board, professionally groom or show your pet? YesNo Do you travel with your pet? YesNo What is your pet's favorite activity? What concerns you about your pet? Bad breath Coughing Ear problems Not eating Weight gain/loss Vomiting Diarrhea Barking Itching/scratching Lameness Problems getting up Increased urination Trouble urinating Trouble defecating House soiling Increase thirst Behavior changes Sores/wounds Separation anxiety Aggression Other Client Services We are pleased to offer a wide range of pet health and client services. Please tell us your areas of interest: Chiropractic Surgical Care Dental Care Holistic Care Nutrition Senior Wellness Behavior Breed Specific Puppy Classes Boarding/Daycare Grooming Referral Program Other Captcha If you are human, leave this field blank. Submit
