New Patient Form

Pet or Pet's Name(Required)

Identifying Marks/Colors(Required)

Owner 1(Required)

Prefix

First

Last

Owner 2(Required)

Prefix

First

Last

Address(Required)

Street Address

City

State / Province / Region

ZIP / Postal Code

Email Address(Required)

(in-house use only)

Owner # 1 Phone

Home

Work

Mobile

Owner # 2 Phone

Home

Work

Mobile

Relation to Owner #1

Place of Employment (Owner 1)

Employer

City

State

Place of Employment (Owner 2)

Employer

City

State

What is the best place and time to reach you?

Preferred method of contact?

How would you like to be contacted for appointment reminders or upcoming services your pet will be due for?

How did you become aware of our hospital(Required)

AAHA

Our Website

Hospital Sign

Care Credit

Personal Recommendation

Great Plains SPCA

Facebook

If personal recommendation, whom may we thank

Have you been to a veterinary clinic or hospital before?

What was your reason for leaving that practice?

Are there any special issues or instructions you would like us to be aware of as we care for your pet?

What health care and / or grooming products are you currently using?

Do we have permission to post pictures of your pet(s) on our clinic social media pages or website?

We will provide you with a written estimate of fees in advance, if in-hospital treatment, surgery or hospitalization is needed. Except for life-threatening emergencies, all procedures and surgeries will require a 50% deposit prior to treatment. Please be aware that all fees are due prior to the release of your pet.

Please provide information for each of the pets you bring to our clinic/hospital

Pet 1

Pet's Name

Species (Dog, Cat, etc.)

Breed

Color or description

Birth date (approx.)

Sex

Neuter/Spayed ?

DA2P/Parvo vac (last given)

Bordetella vac (last given)

FVRCP vac (last given)

Leukemia vac (last given)

Rabies vac (last given)

Heartworm test

Fecal check (worms)

Feleuk test (cat)

Any dental problems?

Allergies? (including drug)

Current medications and/or special diet

Behavioral problems?

Pet 2

Pet's Name

Species (Dog, Cat, etc.)

Breed

Color or description

Birth date (approx.)

Sex

Neuter/Spayed ?

DA2P/Parvo vac (last given)

Bordetella vac (last given)

FVRCP vac (last given)

Leukemia vac (last given)

Rabies vac (last given)

Any dental problems?

Allergies? (including drug)

Current medications and/or special diet

Heartworm test

Fecal check (worms)

Feleuk test (cat)

Behavioral problems?

Pet 3

Pet's Name

Species (Dog, Cat, etc.)

Breed

Color or description

Birth date (approx.)

Sex

Neuter/Spayed ?

DA2P/Parvo vac (last given)

Bordetella vac (last given)

FVRCP vac (last given)

Leukemia vac (last given)

Rabies vac (last given)

Any dental problems?

Allergies? (including drug)

Current medications and/or special diet

Heartworm test

Fecal check (worms)

Feleuk test (cat)

Behavioral problems?

Do you already have an appointment scheduled with us?(Required)

Yes

No

What date and time is your appointment?

*Please note that the last available appointment on Saturday’s is 11:45 AM

Date

Time

:

AM/PM

Owner # 1 Phone

Owner # 2 Phone

Place of Employment (Owner 1)

Place of Employment (Owner 2)

Please provide information for each of the pets you bring to our clinic/hospital

Pet 1

Pet 2

Pet 3

What date and time is your appointment?

Get in touch

913-642-2714

Business Hours

913-642-2714