Patient and Client Information Form

Please complete this form prior to arriving for your scheduled appointment.

Primary Caretaker Information

Name(Required)

First Last

Owner Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Date of Scheduled Appointment(Required)

Please fill out this field ONLY if you have an upcoming, scheduled appointment.

Time of Appointment(Required)

Doctor your pet will be seeing:(Required)

Dr. Bruno

Dr. Dunlap

Dr. Sharma

Additional Caretaker Information

Name(Required)

First Last

Phone(Required)

How did you hear about us?

Please select one of the following:(Required)

Google

Yelp

Hospital Sign

Friend/Family Member

Other

Name of Friend or Family Member (If Applicable)

Pet Information

Pet Name(Required)

Species(Required)

Cat

Dog

Other

Breed(Required)

Description(Required)

Date of Birth(Required)

Sex(Required)

Male

Female

Spayed/Neutered(Required)

Yes

No

Previous Medications

How long has your pet been in your family?(Required)

How many hours does your pet spend outside each day?(Required)

Are there any prior illnesses or surgeries that we should be aware of?(Required)

Are any of the following a concern regarding your pet's typical behavior? Please check all that apply.(Required)

Excessive Barking

Straying From Home

Wetting/Spraying in the House (Cats)

Biting

Smell

Excessive Itching/Scratching

Problem Around Children

Overly Rambunctious/Overly Enthusiastic

Shedding

House Breaking

None of the Above

Is your pet currently on a special diet or medication?(Required)

What are you currently feeding your pet?(Required)

What healthcare or grooming products are you currently using?(Required)

Please list any known drug allergies:(Required)

Do you have an additional pet that will be visiting on the same appointment/day?(Required)

Yes

No

Additional Pet's Name

Species

Cat

Dog

Other

Breed

Description

Sex

Male

Female

Date of Birth

Spayed/Neutered

Yes

No

Previous Medications

How long has your pet been in your family?

How many hours does your pet spend outside each day?

Are there any prior illnesses or surgeries that we should be aware of?

Are any of the following a concern regarding your pet's typical behavior? Please check all that apply.

Excessive Barking

Straying From Home

Wetting/Spraying in the House (Cats)

Biting

Smell

Excessive Itching/Scratching

Problem Around Children

Overly Rambunctious/Overly Enthusiastic

Shedding

House Breaking

None of the Above

Is your pet currently on a special diet or medication?

What are you currently feeding your pet?

What healthcare or grooming products are you currently using?

Please list any known drug allergies:

Do you have a third pet that will be visiting on the same appointment/day?

yes

no

Additional Pet's Name

Species

Cat

Dog

Other

Breed

Description

Sex

Male

Female

Date of Birth

Spayed/Neutered

Yes

No

Previous Medications

How long has your pet been in your family?

How many hours does your pet spend outside each day?

Are there any prior illnesses or surgeries that we should be aware of?

Are any of the following a concern regarding your pet's typical behavior? Please check all that apply.

Excessive Barking

Straying From Home

Wetting/Spraying in the House (Cats)

Biting

Smell

Excessive Itching/Scratching

Problem Around Children

Overly Rambunctious/Overly Enthusiastic

Shedding

House Breaking

None of the Above

Is your pet currently on a special diet or medication?

What are you currently feeding your pet?

What healthcare or grooming products are you currently using?

Please list any known drug allergies:

Please Acknowledge(Required)

I understand that members of my pet’s care team may use a veterinary transcription service that creates an audio recording of conversations during my pet’s appointment for the sole purpose of assisting with medical documentation. If I prefer not to have an audio recording or veterinary transcription service used during my pet’s appointment, I will let a member of the care team know before the appointment begins.

Today's Date(Required)

In order to render service you must acknowledge and accept full financial responsibility for all services provided to your pet at Central Veterinary Hospital. By selecting "agree" you understand that payment is due at the time services are rendered.(Required)

Agree

Disagree (Services will not be rendered)

Signature(Required)

Submit

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