Date *

Name *

First

Last

IMPORTANT

If you, the owner, are not present during an exam, treatment, procedure, or surgery it is very important that we have a current phone number in order to reach you at ANY TIME during such treatments, procedures, or surgeries. Please update this information regularly to avoid miscommunication.

Cell Phone *

Home Phone *

Email *

In an attempt to continue our move toward going paperless, we are starting to integrate email addresses into our client information. This email will not be used for SPAM email; however, it could be a tool to deliver reminders for vaccinations or to transfer documents and records to the client.

Please select a phone that can be reached at ANY GIVEN TIME *

Cell Phone
Home Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

We at Petsvet understand that it may be difficult to personally bring your pet to their appointment. Therefore, we would like the names of any spouse, nurse, caregiver, or friend that may initiate treatment on your behalf. Leave these blank if not applicable.

Name

First

Last

Relation

Name

First

Last

Relation

How did you hear about PetsVet Animal Hospital?

Animal Information

Pet's Name *

Species *

Breed *

Color *

Birthday/Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Add a second pet? *

Yes
No

Pet's Name *

Species *

Breed *

Color *

Birthday/Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Add a third pet? *

Yes
No

Pet's Name *

Species *

Breed *

Color *

Birthday/Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Add a fourth pet? *

Yes
No

Pet's Name *

Species *

Breed *

Color *

Birthday/Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Medical History

If you are visiting this office for the first time, it is important that we receive all prior, and appropriate medical history for your pet. This information could provide useful information in order to properly treat your animal. It is recommended you contact your previous veterinarian and have this information faxed or emailed to our office.

Our office fax number is: 623-974-4775. Our email is staff@petsvet.net for records only.

Has your pet been seen by another Veterinarian? *

Yes
No

May we contact your previous Veterinarian on your behalf to request records for your pet? *

Yes
No

Previous Veterinarian’s Name *

First

Last

Phone *

Date of last physical exam *

Date of last dental exam *

Vaccination History

Has your pet received the following vaccinations?

If “yes”, you will need to provide record of any prior vaccinations, along with any prior medical history. State law mandates that ALL dogs be vaccinated for the Rabies Virus. Furthermore, this clinic strongly recommends vaccinating against the Distemper Virus and Parvo Virus, as both are highly contagious and extra precaution must be taken to prevent further contamination and infection of other animals.

DOGS

Rabies *

Yes
No
Update Today

DA2PPV *

Yes
No
Update Today

Bordetella *

Yes
No
Update Today

CATS

Rabies *

Yes
No
Update Today

FVRCP *

Yes
No
Update Today

FVRC2PL *

Yes
No
Update Today

I understand that state law requires the rabies vaccination for ALL dogs. I also understand that clinic policy requires the Distemper/Parvo vaccination (DA2PPV). *

I understand

I decline vaccination at this time because the required vaccinations are up to date with this clinic or have been given elsewhere. If my pet bites another animal or person while under the care of this veterinary clinic, I will provide proof of current rabies vaccination within 24 hours of notification of incident.

I decline

Owner Responsibility

For Dogs:

It is the owner’s responsibility to maintain control of their pet at all times within Petsvet Animal Hospital. All dogs must remain on a leash AND be kept near the owner at all times. It is also the responsibility of the owner to give a warning to the staff at Petsvet if their pet may be hostile toward people or other animals. If your animal should show aggression toward other animals or the staff, it is the right of the staff of Petsvet Animal Hospital to restrain and apply a muzzle to your animal for personal protection.

For Cats and Smaller Animals:

All cats and smaller animals must be transported within a cage or carrier. If your animal should show aggression toward other animals or the staff, it is the right of the staff of Petsvet Animal Hospital to restrain and apply a muzzle to your animal for personal protection.

I am aware that my pet and my pet’s actions are my own responsibility as an owner. *

I agree

I am aware that this hospital is not staffed 24 hours a day. *

I agree

I have read and understand this authorization of service. *

I agree

Owner/Agent Signature

Clear Signature

I am the owner or agent of the above stated animal and give the authority to execute this consent. I hereby authorize the veterinarian on duty to induce and maintain general anesthesia and to perform the needed and/or requested procedures.

Name *

First

Last

Date *

Online Forms

New Patient Registration Form