New Client Application Client InfoName* First Last Phone*Email* Your Physical Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Appointment Location Preference* Home Visit Clinic (Dixon, KY) NOTE: Home visits are by appointment only.In case of emergencies, are you willing to come to the Dixon location to be seen?* Yes No *Please kindly reconsider us as your new veterinarian as sick visits are spontaneous and home visits are always planned. (We might be 1-2 hours away, may not have all the equipment needed for your pet, may not have specific medication with us, etc).*Reason for Application*Can we take pictures of your pet to put in our computer system, website and Facebook?* Yes No How many pets do you have in your household?*How did you find out about us?* Word of Mouth Facebook Instagram Website Magazine Google Search Current Client Friend or Neighbor Pet's InfoPet Name*Breed*Species*Pet Color*Markings*Pet Birthday* MM slash DD slash YYYY Pet Sex* Male Female Is your pet spayed/nuetered* Yes No Has your pet been bred?* Yes No Where did you get your pet?*How old was your pet when you aquired it?Has your pet had other owners?* Yes No How long has your pet lived with you?*When was your pet last vaccinated?*Why did you choose your pet?*When was your pet's last veterinary exam?*Does your pet have any medical problems?* Yes No List Medical Problems*Is your pet on any medications?* Yes No List Medications*Which parasite preventions are regularly used?*Is your pet allergic to any medications or vaccines?*What brand of food, how much, and how often does your pet eat?*What brand of treats, how much, and how often does your pet eat?*Does your pet eat any other food?* Yes No What specifically?*How is your pet exercised/ maintained? Check all that apply:* Allowed to run free, unsupervised Fenced/ kenneled/ run Leash walked Outside, unleashed but supervised Indoors only Outdoors only How many walks or play sessions does your pet get daily?*How often is your pet groomed?*What percentage of the 24 hour day does your pet spend outside?*What is your pet's living situation?* Apartment Townhouse/condominium House w/ small yard House w/ large yard Farm Where does your pet stay when you are not home for short periods?*Where does your pet stay when you are out of town?*Does your pet travel with you?* Yes No Describe mode, frequency, and destination.*(For example: daily car rides but does not go out of town with you). To the best of your knowledge, are there any litter mates affected with medical or behavioral problems? ** Yes No What specifically?*Why did you choose this pet from the litter?*Why did you choose this breed?*Have you owned this breed before?* Yes No Do you have any of the following behavioral concerns? Check all that apply:* Hiding Trembling Salivation Panting Destructive behavior Running away, escaping enclosure Vocalizing Inappropriate elimination (accidents in the house or outside litterbox, etc) Reactions to noise (vacuum, hair dryer, weed eater, dump truck, siren, alarms, thunder, etc) Aggressive with other animals Aggressive with humans History of biting person or other pet No concerns How often do these behaviors occur?Describe the situations in which each behavioral concern may occur.Does your pet normally require additional restraint for their veterinary care?* Yes No Is your pet aggressive in any way? If so, describe the situations that might trigger aggression.*Do you have any of the following aging concerns (check all that apply):* Locomotory/ ambulation/ movement/ stairs Appetite Bladder Control Bowel Control Vision Hearing Play Interactions Interactions with humans Interactions with other pets Changes in sleep/ wake cycle No concerns Is there anything else that you would like to make us aware of?CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
