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 *

Does your pet have any pre-existing medical conditions we should be aware of (e.g., seizures, heart disease, kidney disease, etc.) *

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 *

Information about you:

Name *

Spouse/Other

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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) *

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

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)

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 do any dental care at home (tooth brushing, dental chews, etc.)? If yes, give details below.

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?

For cats: Is pet indoor only, indoor/outdoor, outdoor only?

Indoor only
Indoor/Outdoor
Outdoor only

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 *

Is your pet on any medications? *

Yes
No

Can your pet have peanut butter? *

Yes
No

When was the last time your pet was seen by a veterinarian? *

Approximate date/year
No prior veterinary visits

Would you like to accompany your pet into the clinic today, or would you prefer a curbside visit and a call from the veterinarian? *

Curbside
In Person

Approximate date/year *

Please provide the name of your pet's prior veterinary clinic(s) *

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?

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 *

New Client Annual Appointment History Form

Complete the New Client Annual Appointment History Form

Complete Your New Client Annual Appointment History Form

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