New Pet FormOwner's InformationName* First Last Client ID Number*Email Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*TypeCellHomeWorkFaxPET INFORMATIONPet's Name*Species*CatDogBreed*Color*Date of Birth (Approximate)*Sex*Intact MaleNeutered MaleIntact FemaleSpayed FemaleUnknownPET QUESTIONNAIREWhich of the following best describes your pet?*Family MemberChild's PetBackyard PetWhere does your pet spend their time?*Indoor onlyOutdoor onlyBothWho was your previous Veterinarian?*Has you 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?*YesNoDo you use a Groomer or Boarding Kennel?*YesNoDo you travel, hike, camp or hunt with your pet?*YesNoAre you currently using any type of flea preventive?*YesNoDoes your pet have a microchip?*YesNoIt 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?*YesNoThe 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)?*YesNoHEALTH RECORDS*DOG OWNERS - Please indicate below to the best of your knowledge the last date your dog has had the followingRabies VaccineDistemper VaccineKennel Cough VaccineLyme BoosterHeartworm TestFecal Test*CAT OWNERS Please indicate below to the best of your knowledge the last date your cat has had the followingRabies VaccineDistemper VaccineLeukemia VaccineLeukemia TestFecal TestDo you consent to photos of your pet being utilized in hospital promotions and on Social Media?*YesNoPlease 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!!!