Animal Hospital at Hillshore

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New Client Check In

If you would like to make an appointment please call us at 608-238-3139. You can assist us to expedite your check in. Please fill out this form and submit it and bring any records for you pet(s). Please submit additonal copys for each pet. Print a copy of this form and bring with your records.

Thank you for your cooperation in letting us assist you.

 

 

Form - New Client

Owner 1 (required)
First Name (required)
Last Name (required)
Owner 2
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Phone (required)
Phone TypePhone Number (required)
Phone
Phone TypePhone Number
Phone
Phone TypePhone Number
Children

Place of Employment

E-Mail Address :
If necessary, May we call you at work?
Yes
No

How did you become aware of our hospital?
Yellow pages
Hospital sign
Web
Personal recommendation

So that we are able to suit your individual needs- which do you feel most applies to you:
Check one
I feel that my pet is another member of our family.
I feel that my pet is just a pet.

Check one
I want the best medical care avaiable for my pet: please recommend anything that you feel is necessary for good health.
I want good medical care for my pet, but there is a limit to what I am to have done.
I want you to perform only the services that I request.

Check one
I want to learn as much as I can about pet health care, please explain in detail what has been done for my pet or what is needed.
I would prefer you just summarize what has been done for my pet or what is needed.
I want my pet healthy, but don't need to know what has been done.

Check one
I prefer to be present when my pet is examined and treated.
I would rather not see my pet examined and treated.

Would you like us to keep you informed about procedures to lengthen you pets life?
Yes
No

Previous Veterinarian?

How old was your pet when you acquired it?

How many hours is your pet outside each day?

What is the best time to reach you at home?

What prior illness or surgery should we know about?

All fees are due upon release of patient. Please indicate your choice of payment.
Cash
Check
MC/Visa

Pet Information
Name (required)

Species (Dog, Cat, Other) (required)

Breed

Description (color) (required)

Date of Birth or Age (required)

Sex (required)

Spayed (female) or Neutered (male) (required)

Dates Vaccinated
DAHPPv (dog)

Bordatella (dog)

DRC (cat)

Rabies (both)

Heartworm test

Fecal Check (worms)

Last Dental

Feline Leukemia Test (cat)

Corona (dog)

Feline Leukemia (cat)

Leptospirosis

On heartworm preventive?
Yes
No

Diet ?

Are any of the following a concern to you in yours pet behavior? Please check.
Excessive Barking
Biting
Shedding
Straying from home
House Breaking
Smell
Problem Around Children
Excessive Itching/Scratching
Wetting/Spraying in House
Overly Rambunctions/Overly Enthusiatic

Would you be interested in learning how to improve your pet's manners?
Yes
No

Is your pet currently on special diet or medications? (If yes what is It)

What health care or grooming products are you currently using?

List any known drug allergies?


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