New Patient Form
General Information
Date
-
Month
-
Day
Year
Date
Owner Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method
Please Select
Phone
Email
Pet Name
Pet Breed
Pet D.O.B or Age
Pet Sex
Please Select
Male
Neutered Male
Female
Spayed Female
Pet Weight
Primary Care Veterinarian
Primary Care Clinic Name
Primary Care Veterinarian Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Would you like us to share your pet's records with them?
Yes
No
Specialty Care Veterinarian
Specialty Clinic Name
Specialty Clinic Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Would you like us to share your pet's records with them?
Yes
No
Please also share my pet's information with:
We do not share your pet’s specific health information/records with anyone without your permission. It is important that we have your pet’s records to review in advance of your appointment. Please contact your primary care doctor and any specialists that your pet has seen to give them permission to share their records with us.
Can we share your pet's progress on social media?
Yes
No
Concern or Issue Information
Please fill out the following in as much detail as possible. Your responses are important for the doctor to have a thorough understanding of what is going on with your pet.
What is the primary reason you are seeking care for your pet?
Has your pet seen your primary care vet or a specialist for this condition?
Yes
No
Were any diagnostic tests (x-rays, bloodwork, ultrasound) completed?
Yes
No
When did you first notice that your pet had a problem and what did you observe?
Has the condition gotten better, worse, or remained unchanged since the initial injury/ issue?
Better
Worse
Unchanged
Please describe what has been happening now vs. before if you have noted a change.
What changes have you noticed in your pet’s behavior or activity?
Do you see signs of pain or anxiety such as panting, pacing, restlessness, licking/chewing at a specific area, shaking/trembling, limping, whining/ crying?
Yes
No
If yes, please describe:
Do you see any signs of weakness such as slipping, scuffing toenails, knuckling, stumbling, difficulty getting up?
Yes
No
If yes, please describe:
Have you noted any pattern with your pet’s condition (better or worse with certain time of day, weather, specific activity or level of activity)?
Yes
No
If yes, please describe:
Does your pet currently have difficulty with, or require assistance for any normal activities (getting up from lying down, walking, stairs/steps, in/out of car, posturing to urinate/ defecate)?
Yes
No
If yes, please describe:
Can you describe your pet’s activity in a typical day/ week? Please list frequency and length of walks (distance of time) and note any changes from what has been normal. Also please note any training or competition that you do regularly or are planning on doing with your pet.
What type of flooring do you have in your home? Does your pet have difficulty rising or turning on any of theses surfaces?
Does your pet have to do stairs on a regular basis?
Yes
No
If so, how many, and how frequently each day?
Do you have other pets in the home that interact with this pet
Yes
No
If so, please describe.
Please list your pet’s main diet as well as any treats fedroutinely. Include brand, formula, amount fed and frequency as well as how long on current diet and previous diet if changed in the last 3 months.
Please list any supplements and medications given regularly or intermittently to your pet. Include brand, formula, strength, dose and frequency as well as any response noted and when started (ok to simply note over 6 months duration vs exact start). Include recently (last 3 months) discontinued products and reason discontinued.
Does your pet have any known or unknown allergies or hypersensitivities? Any adverse reactions to foods, vaccines or medication?
Yes
No
If yes, please describe.
Does your pet have any chronic or previously resolved health issues or injuries?
Yes
No
If yes, please describe.
Does your pet have urinary or fecal accidents? Difficulty posturing or eliminating?
Yes
No
If yes, please describe.
We would like to make your pet as comfortable as possible during their visit. Are there any behaviors or concern that we should be aware of (very shy, fearful, dog reactive, sensitive to touch in a specific area, does not like confined spaces)?
Because some pets can be reactive to men, please indicate any special concerns about your pet being seen by a male staff member during their visit(s).
What is your primary goal for rehabilitation therapy for your pet (i.e., what would you consider a successful outcome)?
Submit
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