New Patient : Form

Step 2 of 2

You made it! Now that you've completed viewing the videos, please complete the form below where you'll begin by answering some questions about them. You'll also need to have your current vet fax over all records for your pet. When you have completed the entire form, press the Submit button to begin the process of securing your first visit!


Please Note: Most fields are REQUIRED. Your form will not submit successfully if all required fields are not completed. Be sure you see the "Thank You! Your form was submitted successfully." message upon clicking Submit.

Allow yourself at least 20-minutes to complete the form below.

STEP 1: Video Introduction
STEP 2: Fax Current Vet Pet Records
STEP 3: Pet Owner Information
STEP 4: Pet Information
STEP 5: Pet Diet
STEP 6: Pet Health History
STEP 7: Pet Illness History
STEP 8: Pet Emotional & Behavioral Assessment


STEP 1 : VIDEO INTRODUCTION
Thank you for watching these educational videos! Viewing is required to ensure you have a sense of the services we offer and a better understanding of what you can expect at your first office visit.
Yes! I watched the videos *
You must watch the videos to better understand our service before completing this form.
Video Survey *
We know this can be hard for some to digest, so please let us know your immediate reaction. Select all that apply.
Please tell us any other immediate reactions or thoughts you have after viewing these videos.
STEP 2 : FAX CURRENT PET VET RECORDS
Before you submit this New Patient Form, please call your current veterinary clinic and have them fax over all records for your pet to us. Our fax number is 586-314-0249.
Yes! I've called my current vet to fax over records! *
We must have your pet's records to secure their first new patient visit. Please confirm below.
Please list the date you called your vet to request fax records.
STEP 3 : PET OWNER INFORMATION
Name *
Name
Address 1 *
Address 1
Preferred Phone Contact Number *
Phone : Mobile
Phone : Mobile
Text OK?
Phone : Home
Phone : Home
Phone : Work
Phone : Work
Secondary Caregiver *
boyfriend, girlfriend, friend, neighbor, cousin, aunt, uncle, etc.
Name : Secondary Caregiver
Name : Secondary Caregiver
Phone Number : Secondary Caregiver
Phone Number : Secondary Caregiver
STEP 4: PET INFORMATION
Species *
Sex *
Spayed / Neutered *
Approximate date or age if not known
How old was your pet when you got it?
Obtained Pet From *
STEP 5 : PET DIET
Dry, Canned, Dehydrated, Raw, Cooked, Fruits & Veggies, Treats, or Other.
Brand : Taste Of The Wild. Formula : Pacific Stream, Dy. Please be as detailed as possible
1, 2, 3, More
List all quantities and types of food your pet eats daily
5 years, 5 weeks, etc
STEP 6 : PET HEALTH HISTORY
Vaccinations *
Check all that apply
Titer Testing *
Check all that apply
Heartworm *
I use heartworm preventative medication each year.
If you are giving heartworm preventative medications, please list specific type.
If you are giving heartworm preventative medications, which months are you giving them?
Flea & Tick *
I use flea medications each year to prevent infestation.
If you are giving pest preventative medications, please list specific type.
If you are giving pest preventative medications, which months are you giving them?
I use natural Flea & Tick products *
If applicable, please list below.
STEP 7 : PET ILLNESS HISTORY
Examples like skin allergies, ear infections, eye infections, diarrhea, vomiting, cysts
STEP 8 : PET EMOTIONAL & BEHAVIORAL ASSESSMENT
My pet prefers: (Please check all that apply) *
Phobias if any: (Please check all that apply) *
Please fill in any other phobias below
By submitting this form, you're beginning the process to secure your pet's first visit on the path to a Foundation of True Health! We will call you soon to schedule your first appointment and secure your deposit of $120.00 (non-refundable).