"*" indicates required fields Please complete your New Client Form prior to your first appointment. We look forward to meeting you soon!Owner's Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail* Which number is best to reach you?* Home Cell Can you receive text messages?* Yes No Preferred method of communication?* Phone Email Text Driver's License*Driver's License State*Add a Co-Owner?* Yes No Name* First Last Home Phone*Cell Phone*Pet Health HistoryPet's Name*Breed*Color*Sex* Male Female Neutered/Spayed?* Yes No Birthdate or Age*Current MedicationsPlease bring and give any medical records/vaccine records to the receptionists to make copies.Diet And EnvironmentWhat food does patient currently eat?*Amount & Frequency?*Is your pet on any dietary supplements?* Yes No Does your pet consume table food?* Yes No Is your pet primarily indoor or outdoor?* Indoor Outdoor Are there any other animals in the household?* Yes No Do you have your pet groomed or boarded outside of your home?* Yes No Do you travel outside of Florida with your pet?* Yes No Past HistoryHas your pet had any prior illnesses, accidents, or surgeries* Yes No Is your pet aggressive or fearful around strangers?* Yes No Is your pet on heartworm, flea/tick preventatives?* Yes No Please list any other medications or supplements your pet receives.Does your pet have any known allergies to any medications?* Yes No Has your pet ever had a reaction to any vaccines?* Yes No To allow for ample time with all patients and surgical procedures. We request clients be on time for their scheduled appointments and procedures. If you are 15 minutes late to your appointment, you may be asked to reschedule your appointment. Upon receipt of this request, our receptionist will reach out to you with the first available appointment time that coincides with your preferences. If we are unable to reach you or do not hear back from you within 24 hours, we will be unable to reserve your spot on the schedule. If you need to cancel an appointment, we ask you give a minimum of a 24-hour notice. This will allow us to better accommodate those individuals seeking immediate care. We strive to accommodate all emergency situations and unforeseen circumstances; however, please know these situations may be subject to additional fees. We ask that in any emergency, you CALL to advise our staff of your arrival, so that we may prepare accordingly. DO NOT submit an appointment request for an emergency. For your convenience, we offer limited same day appointments for urgent care and sick patients, but they fill up fast, so we recommend calling first thing in the morning. I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal.* I have read and agreeDo we have your permission to share your pet’s image and story on our social media, website, and other forms of related media?* Yes No Will you be using pet insurance?* Yes No I authorize my emergency contact (other than myself) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18.* I have read and agreeEmergency Contact* First Last Emergency Contact Phone*Signature*Date* MM slash DD slash YYYY
