At Telford Veterinary Hospital, we strive to "never be the reason a pet or family doesn't get the very best care possible".  To help is accomplish this, please fill out this form as completely as possible and click the submit button at the bottom of the form.  The form contains required feilds for submission, if you do not know the answer please reply with an "unknown".  The form should only take a couple minutes to complete but will save valuable time during your first visit.

Form - Online New Client Form

OWNER'S INFORMATION
Owner's Name (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
Owner's Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
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Peferred Phone Number (required)
Phone TypePhone Number (required)
Secondary Phone Number
Phone TypePhone Number
Driver's License Number and State of Issue (required)

What is the best time of day to contact you? (required)
No preference
Daytime
Evening

Additional Contact Person (required)

Additional Contact Person Phone Number (required)

EMPLOYER
Employer's Name (required)

Employer's Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
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PAYMENT POLICY
All fees are due at the time services are rendered.
If you have any questions about projected costs, please let us know. We will be happy to provide you with an Medical Care Plan outlining costs.
Preferred Method of Payment (check all that may apply) (required)
Cash
Check
Visa
Mastercard
Discover
American Express
Debit Card
CareCredit
REFERRAL
How did you become aware of Telford Veterinary Hospital? (required)
Drive by
Yellow Pages
Deal of the Day
Community Event
Pampered Pets
Internet
Media Advertising
Personal recommendation

If a Personal Recommendation, who referred us? (so we can show our thanks)

PET INFORMATION
Pet's Name (required)

Species (required)
Cat
Dog
Other (specify below)

If species is listed as Other please note species type below

Breed (required)

Color (required)

Date of Birth (Approximate) (required)

Sex (required)
Intact Male
Neutered Male
Intact Female
Spayed Female
Unknown

PET QUESTIONNAIRE
Which of the following best describes your pet? (required)
Family Member
Child's Pet
Backyard Pet

Where does your pet spend their time? (required)
Indoor only
Outdoor only
Both

Who was your previous Veterinarian? (required)

Has you pet had any serious illnesses or surgeries? (required)

Does your pet have any allergies to vaccinations or medications? (required)

Is your pet on any special diets or medications? (required)

Would you like to be present during the treatment of your pet? (required)
Yes
No

Do you use a Groomer or Boarding Kennel? (required)
Yes
No

Do you travel, hike, camp or hunt with your pet? (required)
Yes
No

Are you currently using any type of flea preventive? (required)
Yes
No

Are you currently using any type of tick preventive? (required)
Yes
No

Does your pet have a microchip? (required)
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? (required)
Yes
No

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)? (required)
Yes
No

HEALTH RECORDS
*DOG OWNERS
Please indicate below to the best of your knowledge the last date your dog has had the following
Rabies Vaccine

Distempter Vaccine

Kennel Cough Vaccine

Lyme Booster

Heartworm Test

Fecal Test

*CAT OWNERS
Please indicate below to the best of your knowledge the last date your cat has had the following
Rabies Vaccine

Distemper Vaccine

Leukemia Vaccine

Leukemia Test

Fecal Test

Please include any additional information regarding your pet that you feel may be important to us.

THANK YOU FOR THE OPPORTUNITY TO CARE FOR YOUR PET!!!