Client Information Form

Owner's Information

Name*

First Last

Address*

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

Phone*

Type

Email*

Secondary Phone

Type

Additional Contact Person*

Additional Contact Person Phone Number*

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.

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

Cash
Check
Credit
CareCredit

Check all that may apply

Referral

How did you become aware of Telford Veterinary Hospital?

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

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: 64 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

Who is your pet’s previous Veterinarian?*

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

Drop files here or

Max. file size: 64 MB.

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

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Telford Veterinary Hospital

Owner's Information

PAYMENT POLICY

Referral

PET INFORMATION

PET QUESTIONNAIRE

Our Location

Appointments