Name *

First

Last

Pronouns (Optional)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Address where housecall appointment will take place

Gate Code

Email *

Primary Phone *

Does this number receive text messages? *

Yes
No

Secondary Contact Name

First

Last

Pronouns (Optional)

Secondary Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Contact Email

Secondary Contact Phone

Does this number receive text messages?

Yes
No

How did you find out about us? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Weight (approximate) *

Sex *

Male
Neutered Male
Female
Spayed Female

Is your pet currently taking any medications? *

Yes
No

Please list all current medications, including name, dosage, and frequency *

Does your pet have any known allergies or medical conditions? *

Yes
No

If yes, please explain *

Has your pet ever had a vaccine reaction? *

Yes
No

If yes, please explain *

Please answer the following questions as completely as possible. Understanding your pet's behavior in advance will help us create a more comfortable environment during the visit.

Is your pet scared of the vet? *

Yes
No

Has your pet ever bitten or attempted to bite? *

Yes
No

Has your pet ever worn a muzzle? *

Yes
No

Does your pet take medication to help keep calm for a vet visit? *

Yes
No

What medication? *

Is your pet sensitive or painful in any specific areas of the body? *

Yes
No

Please describe *

Would you like to add an additional pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Weight (approximate) *

Sex *

Male
Neutered Male
Female
Spayed Female

Is your pet currently taking any medications? *

Yes
No

Please list all current medications, including name, dosage, and frequency *

Does your pet have any known allergies or medical conditions? *

Yes
No

If yes, please explain *

Has your pet ever had a vaccine reaction? *

Yes
No

If yes, please explain *

Please answer the following questions as completely as possible. Understanding your pet's behavior in advance will help us create a more comfortable environment during the visit.

Is your pet scared of the vet? *

Yes
No

Has your pet ever bitten or attempted to bite? *

Yes
No

Has your pet ever worn a muzzle? *

Yes
No

Does your pet take medication to help keep calm for a vet visit? *

Yes
No

What medication? *

Is your pet sensitive or painful in any specific areas of the body? *

Yes
No

Please describe *

Would you like to add an additional pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Weight (approximate) *

Sex *

Male
Neutered Male
Female
Spayed Female

Is your pet currently taking any medications? *

Yes
No

Please list all current medications, including name, dosage, and frequency *

Does your pet have any known allergies or medical conditions? *

Yes
No

If yes, please explain *

Has your pet ever had a vaccine reaction? *

Yes
No

If yes, please explain *

Please answer the following questions as completely as possible. Understanding your pet's behavior in advance will help us create a more comfortable environment during the visit.

Is your pet scared of the vet? *

Yes
No

Has your pet ever bitten or attempted to bite? *

Yes
No

Has your pet ever worn a muzzle? *

Yes
No

Does your pet take medication to help keep calm for a vet visit? *

Yes
No

What medication? *

Is your pet sensitive or painful in any specific areas of the body? *

Yes
No

Please describe *

Previous Vet Clinic

Previous Vet Clinic's Phone Number

May we request records from your previous vet clinic?

Yes
No

Briefly describe why you are scheduling this appointment: *

Safety Agreement: For our safety, we require all dogs to be leashed and well-controlled when we arrive. Cats should be confined to a carrier or a room with no furniture, such as a bathroom; no bedrooms, please. We will proceed without a leash or confinement once safety and comfort have been established. Additionally, threatening behavior OF ANY KIND will not be tolerated by any human participants. This includes verbal and physical aggression. We reserve the right to end the visit if conditions are unsafe, and you will be billed for services rendered up to that point, including the house call and the exam fees. *

I have read and understand.

Payment is due in full at the time that services are performed. We accept Cash, Check, Visa, MasterCard, Discover, and American Express. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

If we take photos of your pet during our visit, do we have your permission to include them in our social media posts? *

Yes
No

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