"*" indicates required fields Client InformationPrimary Owner's Name* First Last SSN#(only if paying w/ check)Co-Owner/Spouse First Last SSN#(only if paying w/ check)Home Address* Street Address Address Line 2 ZIP Code Primary Phone Number*Co-Owner/Spouse Phone NumberEmail* EmployerEmployer PhoneHow did you hear about us?*Family or friendLive in areaGoogleFacebook (Meta)InstagramYelpOtherOther*Doctor Preference: Dr.Kaya Dr.Fry Dr.Dang Dr.Kwock Dr.Lee Patient InformationPet's Name*Type of pet* Dog Cat Other Sex* Male Female Neutered / Spayed?* Yes No Birthday / AgeBreedColor / MarkingsMy pet is Indoor only Indoor / Outdoor Outdoor only Brand(s) of pet foodMy pet's food is Wet Dry Treats?Flea / Tick meds:(Nexgard, Trifexis, Cheristin, Advantix, Capstar, Sentinel, Revolution, Simparica, etc.)Heartworm meds:(Heartgard, Trifexis, Revolution, Simparica TRIO, Sentinel, etc.)Has your pet ever shown aggression to family members, unfamiliar people, or other animals?* Yes No Last veterinary clinic seen/Date of last vaccinations:(if records aren't present)Please check any symptoms or problems you’ve noticed with your pet: Increased/Decreased Appetite Behavioral Changes Coughing/Sneezing/Hacking Ear Disorders Excessive Thirst and/or Urination Halitosis (Bad Breath) Skin Concerns/Fleas/Ticks Eye Disorders Diarrhea Vomiting/Dry Heaving Limping Other Ear Disorders:Eye Disorders:OtherHow do you plan to pay for today’s visit?* Cash Check Credit Card Consent* After carefully reading the content below, I agree to all.I hereby authorize the veterinarian to examine, prescribe for, and treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. WE DO NOT BILL. After carefully reading the above, I sign in agreement. Full Owner/Responsible person's name*Signature of pet owner/guardian*Date* MM slash DD slash YYYY
