New Patient Consultation Form

Client Information

First Name

Last Name

Co-Owner First Name

Co-Owner Last Name

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Email

Phone Number

Secondary Phone Number

Patient Information

Pet's Name

Breed

Male / Female

Spayed / Neutered

Age / DOB

Approximate Weight (lbs)

Who is your primary veterinarian/ clinic and have you seen any other veterinarians for this issue?

What is the reason for this consultation? Please specify condition and which body part is affected.

How long has this been going on?

Is the condition getting better, worse or the same?

What current medications and supplements is your pet receiving? Do any of these seem to help? If so, which ones?

Are there any known allergies or problems with medications?

What is your pet currently eating? Please specify food type, brand, protein and quantity per day as well as any additional treats and people food.

Does your pet have known food allergies or sensitivities?

What is you pet's current activity level, frequency and duration? What was their activity level prior to any injury? Please include walks, dog park visits and other physical activities.

Is there any activity or situation that makes the current condition worse? Better?

What are your realistic goals? What would you like to get out of this consultation?

How did you hear about us?

Do you have pet insurance? If so, which one?

May we take photos of your pet and possibly use them for social media posts / marketing?

Yes

No, thank you

I acknowledge that a deposit equivalent to the consultation fee is required to secure an appointment. I also acknowledge that this deposit is non-refundable if the appointment is canceled with less than 48 hours notice or I am more than 15 minutes late to the scheduled appointment.