"FIRST VISIT" Form

Thank you for giving CARE the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following as this will save significant time during your first visit and will allow us more time for therapies.

Please complete all three parts of the form before submitting.

PET OWNER INFORMATION

First Name, Last Name: *

Spouse / Partner Name:

ADDRESS

Address: *

City: *

State: *

Zip Code: *

CONTACT INFO

Home Phone: *

Work Phone:

Cell Phone:

Email address: *

OTHER INFO

Whom may we thank for your visit?:

Please enter name and address if known

How did you hear about us?: *

Other? Please explain:

If you selected "other", please explain:

PRIMARY VETERINARIAN INFORMATION

Please provide contact information of your pet's primary Veterinarian so that we can keep them posted about treatments provided by CARE.

Vet's Name: *

Animal Hospital:

Phone Number: *

Email address:

PET INFORMATION

Please complete information for all your pets.

General Health Info

Pet's Name: *

Species: *

(Dog, Cat, etc..)

Breed:

Date of Birth (approximate): *

Sex: *

Neutered or Spayed?: *

General Pet Condition

What is the primary reason for your visit?: *

Are any of following conditions below or above normal level?:

Use CTRL key to select more than one condition

Please describe conditions other than normal:

Please describe conditions other than normal

History of Surgeries

Besides Spaying or neutering has you pet had any surgeries? If so, please explain what type and when.

Describe type and time of surgeries:

Legs and Joints

Has there been any lameness?: *

Use CTRL key to select more than one leg

Does the animal bear any weight on affected leg(s)?:

Yes

Lameness observed before?:

Food and Diet Related Information

Food and Diet Info:

Medications and Supplements

Note: Distemper/Parvo/Bordetella vaccines or titers will be required to be current if a pet is dropped off for treatments.

Medications and Supplements:

Other observations, concerns and/or medical problems?

Please use the box below to decribe any other medical concerns and problems not mentioned in this form

Other observations, concerns and/or medical problems provided by Client:

Getting Started

Rehabilitation Services

Exercise and Wellness

First Visit

Hours

Location