Forms

New Client Registration Form

Save time during your next appointment. Complete your new client form online from any device at any time before your visit.

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New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pets before your visit.

Pet Owner

Name *

First

Last

Secondary Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Preferred Contact Method *

Phone
Email

How did you hear about our hospital? *

Drive by
Internet
Referral
Other

Patient Information

Layout

Pet Name *

Breed *

Layout (copy)

Sex *

Color *

Date of Birth or Age *

Number of pets in household (specify dogs, cats, or other species) *

Pet Acquired From

Medical History

Previous Animal Hospital or DVM Name

City of Previous Hospital

Phone (If known)

Do we have permission to contact for records? *

Pet Questionnaire

Does your pet show any reluctance to getting in the carrier or car?

How would you describe your pet’s reaction to going to the veterinary hospital?

Eager and excited
Subdued
Reluctant
Somewhere in between

How would you describe your pet around other animals and people, such as in the lobby area of the veterinary hospital?

Dislikes seeing other dogs
Dislikes other pets approaching
Dislikes people passing by
Dislikes being approached by people
Dislikes loud noises/large groups

Are there things you or your pet did not like during past veterinary visits?

Being weighed
Getting on the exam table
Having a procedure done
Being handled by veterinary staff
Walking into/through the clinic

Has your pet ever been prescribed any medications or required sedation to help with a visit to the veterinary hospital?

Does your pet or any member of your family have any FOOD ALLERGIES?

Thank you for allowing us to care for your pet!

Signature

Book an Appointment

Keeping up with your pet’s health is important. Book an appointment today!

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Our Hours

Mon – Fri: 8 am to 5 pm
Sat – Sun: Closed

Thank you for choosing us as your partner in pet care!

After Hour Emergency Care

If your pet is facing an emergency outside of our operating hours, please refer to Animal Emergency Clinic of Rockford.