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Drove by Google Facebook Yelp Other ReferralIf other, please explainWho referred you?Do you have an appointment scheduled? *(Required) Yes NoAppointment Date(Required) MM slash DD slash YYYY Appointment Time(Required) Hours: Minutes AMPM AM/PMPet Health HistoryPet's Name(Required)Sex(Required) Male FemaleNeutered/Spayed?(Required) Yes NoBreed(Required)Color(Required)Birthday or Age(Required)Current MedicationsPlease bring and give any medical records/vaccine records to the receptionists to make copies.What food does the patient currently eat?(Required)Amount & Frequency?(Required)Is your pet on any dietary supplements?(Required) Yes NoWhat kind and dosage?(Required)Does your pet consume table food?(Required) Yes NoPlease explainIs your pet primarily indoor or outdoor?(Required) Indoor OutdoorAre there any other animals in the household?(Required) Yes NoPlease explainDo you have your pet groomed or boarded outside of your home?(Required) Yes NoHow often?Has your pet had any prior illnesses, accidents, or surgeries?(Required) Yes NoPlease explainIs your pet aggressive or fearful around strangers?(Required) Yes NoPlease ExplainIs your pet on heartworm or flea/tick preventatives? *(Required) Yes NoHow frequently?(Required) Year-round SeasonallyPlease list any other medications or supplements your pet receives.Does your pet have any known allergies to any medications?(Required) Yes NoIf yes, please list:Has your pet ever had a reaction to any vaccines?(Required) Yes NoIf yes, please list:Do you want to add another pet?(Required) Yes NoPet's Name(Required)Sex(Required) Male FemaleNeutered/Spayed?(Required) Yes NoBreed(Required)Color(Required)Birthday or Age(Required)Current MedicationsPlease bring and give any medical records/vaccine records to the receptionists to make copies.What food does the patient currently eat?(Required)Amount & Frequency?(Required)Is your pet on any dietary supplements?(Required) Yes NoWhat kind and dosage?(Required)Does your pet consume table food?(Required) Yes NoPlease explainIs your pet primarily indoor or outdoor?(Required) Indoor OutdoorAre there any other animals in the household?(Required) Yes NoPlease explainDo you have your pet groomed or boarded outside of your home?(Required) Yes NoHow often?Has your pet had any prior illnesses, accidents, or surgeries?(Required) Yes NoPlease explainIs your pet aggressive or fearful around strangers?(Required) Yes NoPlease ExplainIs your pet on heartworm or flea/tick preventatives? *(Required) Yes NoHow frequently?(Required) Year-round SeasonallyPlease list any other medications or supplements your pet receives.Does your pet have any known allergies to any medications?(Required) Yes NoIf yes, please list:Has your pet ever had a reaction to any vaccines?(Required) Yes NoIf yes, please list:Office Policies To allow for ample time for all patients and surgical procedures, Claremont Veterinary Hospital operates primarily by appointment. We request all our clients be on time for scheduled appointments and procedures. If you are 15 minutes late to your appointment, you may be asked to reschedule your appointment. We do take emergencies; however, these services may be subject to a higher fee schedule. For your convenience, we offer limited same-day appointments for urgent care sick patients. They fill up fast, so we recommend calling first thing in the morning.For your protection, and that of others, pets should be properly restrained by a leash or carrier upon arrival. If your pet requires special accommodations, please give us a call when you arrive so we can assist you and your pet.If you must cancel an appointment, we ask for 24 hours’ notice. For surgical appointments, we ask for a 48-hour cancellation notice.We accept cash, debit, or all credit cards. We also offer CareCredit.We would be more than happy to fill your prescriptions or have your food orders ready for pick-up. Please call ahead or use our website to process refills. Please allow 24-48 hours for prescription refills. Special orders or controlled substances may require longer.I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal.(Required) I have read and agree.I understand that payment is ALWAYS DUE IN FULL at time of service. A deposit of 50% of the treatment plan may be required before treatments or hospitalization of your pet. I recognize that financial concerns should be discussed PRIOR to examination and treatment.(Required) I have read and agree.I understand there are limited new client slots due to the overwhelming demand for veterinary care. By checking this box, I am committing to using Claremont Veterinary Hospital as my primary care veterinarian. A $75 exam fee deposit will be required to hold your first appointment.(Required) I have read and agree.Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media?(Required) Yes NoI authorize my emergency contact (other than myself) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18.(Required) I have read and agree.Emergency Contact(Required) First Last Emergency Contact Phone(Required)Date(Required) MM slash DD slash YYYY Signature(Required)Records UploadMax. file size: 128 MB.CAPTCHAΔ
