902-407-4570
info@russelllakevet.com
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New Client Annual Appointment History Form
Complete the New Client Annual Appointment History Form
BOOK APPOINTMENT
Complete Your New Client Annual Appointment History Form
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Information about the pet we will be seeing:
Name
*
Species
*
Canine
Feline
Breed
*
Color
*
Date of Birth/Age
*
Gender
*
Female
Male
Spayed or neutered
*
Yes
No
Any Known Allergies/Reactions?
*
Yes
No
If yes, please explain
*
Who was your pet’s previous veterinary clinic?
No prior veterinary clinics (new pet, puppy, etc)
Please list prior clinic(s):
*Please bring any paperwork provided by the adoption agency, shelter, breeder, etc with you to their visit or text photos of the records to
607-733-6503
*
Please list prior clinic(s):
When was the last time your pet was seen by a veterinarian?
Approximate date/year
*
No prior veterinary visits
*
*If the vaccine was performed at a Rabies clinic, please bring the certificate of the most recent vaccination or text a photo of the certificate to
607-733-6503
*
Information about you:
Name
*
Spouse/Other
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary phone number
*
Secondary number
Spouse phone number
Other Phone Numbers
Email Address
*
I would like to receive my pet's reminders by email
*
Yes
No
Whom may we thank for referring you to us? (check one)
*
Friend or Relative: If they are clients at our hospital, whom may we thank?
Google Search
Facebook
Instagram
Drove By
Staff Member
Shelter or Pet Store
Other
If they are clients at our hospital, whom may we thank?
*
Staff Member
*
If other, please explain
*
Credit Policy: We ask that all fees be paid at the time of service.
*
I have read and understand.
Please see our
Payment Options
Social Media/Photo Permission: Do we have your permission to post photos of your pet online?
*
Yes
No
Who should we contact to make medical decisions at your pet's appointment?
*
Owner (Named Above)
Someone Else (Named Below)
Reason for visit: (check all that apply)
*
Annual Physical
Heartworm/Tick test (dogs)
Fecal/intestinal parasite screen
Deworming treatment
Annual physical - unsure of other services that are due. Would like to discuss with veterinarian.
Dog vaccines
DHPP
Lepto
Rabies
Lyme
Bordetella
Unsure, would like to discuss recommendations with veterinarian
Feline vaccines
FVRCP/Distemper
Rabies
Feline Leukemia (FeLV)
Unsure, would like to discuss recommendations with veterinarian
Other procedures: (All procedures at additional cost)
*
Anal glands
Nail trim
Ear cleaning
Have you noticed any issues/problems with your pet? Are there any concerns for the following: (check all that apply)
Eating (increased or decreased appetite)
Drinking (increased or decreased)
Weight Loss
Weight Gain
Itching/Scratching
Shaking Head
Bad Breath
Vomiting
Diarrhea
Urination Issues
Excessive Sleeping
Scooting
Difficulty Rising
Skin Masses (explain below)
Car Sickness
Behavioral Problem
Other (explain below)
Skin Masses (explain below)
*
If other, please explain
*
If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?
Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?
*
Yes
No
What brand and type of food do you feed your pet?
*
What food do you feed?
*
How much do you feed?
*
Free fed (food is offered always/whenever hungry)
Measured amount (specify how much and how often)
Measured amount (specify how much and how often)
*
Do you have insurance for your pet?
*
Yes
No
Do you give your pet heartworm or flea/tick preventative?
*
Yes (specify product(s) and last time given)
No
If yes, specify product(s) and last time given
*
Do you wish to take home flea/tick/heartworm prevention today?
*
Yes
No
Unsure, speak with a veterinarian about recommendations for my pet
What percentage of time does your pet spend outside?
Have you seen any fleas or ticks on your pet?
Yes (specify - fleas or ticks?)
No
If yes, fleas or ticks?
*
Do you have other pets?
*
Yes
No
Does your pet come into contact with other dogs? Please check all that apply
*
None
Boarding
Grooming
Dog Parks
Other
Is your pet on any medications?
*
Yes
No
When was the last time your pet was seen by a veterinarian?
*
Approximate date/year
No prior veterinary visits
Approximate date/year
*
Please provide the name of your pet's prior veterinary clinic(s)
*
Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations.
I understand that financial responsibilities for services are rendered at the time of discharge.
*
I have read and understand.
I give Russell Lake Animal Hospital authorization to treat as discussed above.
*
I have read and understand.
Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days?
*
Yes
No
Have you or anyone in your house experienced the following symptoms in the past 14 days?
Cough
Shortness of breath
Fever
Sore throat
Chills
Muscle pain
Headache
New loss of taste or smell
Who experienced these symptoms?
Self
Someone else in the house
No symptoms
*If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment.
*
I have read and understand.
Please arrive a few minutes early or on time to check in. Late arrivals may not be accommodated and a late fee of $50 may be applied to your account. We ask that you remain masked while in the examination room. Once the exam has been performed and a plan has been discussed we will proceed with providing treatment.
*
I have read and understand.
I have read and understand. Social Media/Photo Permission: Do we have your permission to post photos of your pet online?
*
Yes
No
Please type your initials.
*
Date
*
Email
Submit