Please Complete the Following Information Form

Please complete the following information:

Appointment Location(Required)

Appointment Date(Required)

Primary Caretaker Information

Name(Required)

First Last

Address(Required)

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

Home Phone

Business Phone

Cell Phone/Other(Required)

Fax

Email(Required)

Primary Caretaker Date of Birth(Required)

(For controlled drug dispensing)

How did you hear about us?(Required)

Additional Caretaker Information

Name

First Last

Additional Caretaker Business Phone

Additional Caretaker Cell Phone/Other

Additional Caretaker Email

Pet Information

Pet Name(Required)

Breed(Required)

Sex(Required)

Color(Required)

Pet's Age(Required)

Do you have more than one pet scheduled for this appointment?(Required)

If so, please add the additional pet's information in the designated fields that appear below.

Pet Health History

Who is your primary care veterinarian?(Required)

Veterinary Hospital Name(Required)

Has your pet had any noticeable problems with their eyes? If so, please describe below:(Required)

Does your pet have any known health conditions? (example: diabetes, cushings, thyroid disorders, etc.)(Required)

List any medications or supplements that you give to your pet: (including flea/heart guard protection, or supplements such as fish oil).(Required)

Has your pet recently traveled outside its usual environments, particularly if they have visited different cities, states, or countries?(Required)

Are there other pets at home? If yes, please describe.(Required)

What food does your pet eat?(Required)

Does your pet have a history of seizures?(Required)

Has your pet had any surgeries or procedures? (please include spay, neuter, dental cleaning, etc.)(Required)

Additonal Pet Information

Pet Name(Required)

Breed(Required)

Sex(Required)

Color(Required)

Pet's Age(Required)

Additional Pet Health History

Has your pet had any noticeable problems with their eyes? If so, please describe below:(Required)

Does your pet have any known health conditions? (example: diabetes, cushings, thyroid disorders, etc.)(Required)

List any medications or supplements that you give to your pet: (including flea/heart guard protection, or supplements such as fish oil).(Required)

Has your pet recently traveled outside its usual environments, particularly if they have visited different cities, states, or countries?(Required)

Are there other pets at home? If yes, please describe.(Required)

What food does your pet eat?(Required)

Does your pet have a history of seizures?(Required)

Has your pet had any surgeries or procedures? (please include spay, neuter, dental cleaning, etc)(Required)

Appointment Reminders

We understand how busy life can get, and we're committed to making your experience with us as smooth and convenient as possible. To help you manage your pet's healthcare needs, we offer appointment reminders via text message. We hope these reminders will ensure that you don't miss your scheduled appointments. However, if something unexpected arises, please contact us as soon as possible. We'll do our best to find the next available appointment that suits your schedule.

By providing your mobile number, you will automatically be enrolled in our text message reminder service. If you prefer not to receive these reminders, please let us know and we will remove you from the service. You may opt out at any time.

Select yes if you wish to receive text message appointment reminders:(Required)

Payment and Cancellation Policy

Your understanding of our Payment and Cancellation Policy is crucial to maintaining a smooth process for all our clients and their pets. We require a pre-paid deposit of $115 for the Wellness Exam at the time of scheduling.

If for any reason you cannot keep an appointment, please provide at least 24 business hours' notice (Monday - Friday) to avoid a cancellation fee of $65 for the missed service or a $115 missed wellness exam fee. Your understanding and adherence to this policy not only allows us to better serve you but also helps us to accommodate other pets who need our attention.

By signing below, you acknowledge that you understand and agree to take full financial responsibility for the pet listed and that you accept our Payment and Cancellation Policy.

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