AAHA
Online New Client/Pet Information Sheet

Upon your pet's first visit to Shaker Veterinary Hospital, you will be asked to provide us with information about yourself and your pet so that we may better serve you. We have made this form available online as a courtesy to our clients. When you arrive for your first visit, please mention to the receptionist that you have submitted the online New Client Information form and they will retrieve the completed form for you to sign.

When you submit the form below, we also send you a copy of the form to the E-mail address you provide, so please be careful to enter your address accurately. The completed form will be attached to the message you receive in Adobe Acrobat PDF format, and there will be instructions for how to acquire the Adobe Acrobat viewer in the event that your computer is not currently equipped with this software.


*First Name:

*Last Name:

 MI:

*Address: 

*City:

*State:

*Zip:

*Phone:

*Business Phone:

*Email:

*Occupation:

*Employer Name:

Employer's Address: 

City:

State:

Zip:

Spouse's Name:

Spouse's Employer:

Phone:
           
           
  Pet #1 Pet #2 Pet #3
Dog
Cat
Pet's Name
Breed
Color
Date of Birth or Age
Sex Male  Female Male  Female Male  Female
Altered
Dog
Rabies (Date Given) 
DHLP-P (Date Given) 
Bordatella (Date Given) 
Cat
Rabies (Date Given) 
FDV-RTC (Date Given) 

Other Information

In case of emergency, if we cannot reach you, whom should we call?

Name:             Phone:                   Relationship:

Referred/Recommended By:               Previous Veterinarian:

Is your pet microchipped?  No  Yes

Usual Diet (Include Brand Names)  

How long have you had your pet?   

How did you acquire your pet?       

Is your pet allergic to Drugs, Food or Fleas?  No Yes

If yes, please specify:

List any major disease, illness, or injury your pet has had:

Currently of medication? No Yes    Specify

I certify that I am the owner of the animal(s) listed above.  I am at least eighteen (18) years of age and I assume total financial responsibility for the costs of services rendered by Shaker Veterinary Hospital, PC.   

I acknowledge that I am not the owner of the animal(s) listed above.  I have been authorized by the owner to act on their behalf.  I certify that I am at least eighteen (18) years of age and I assume total financial responsibility for the cost of services rendered by Shaker Veterinary Hospital, PC as well as responsibility for the decisions regarding care and treatment of the animal(s) described herein. 

Appointment Checklist

  1. Bring in a stool sample if the patient has not had a sample checked within the previous year or has diarrhea.
  2. Bring in a urine sample if the animal has bloody urine, is straining to urinate, or is drinking or urinating excessively.
  3. If your pet has been vaccinated elsewhere, bring the medical records so we can update our records.
  4. If the patient is being brought in for a second opinion, bring previous medical records, X-Rays, and laboratory test results, to provide the doctor with as much information as possible.
  5. If your animal is on any medications, bring the name, strength and dose or the medication itself




© Shaker Veterinary Hospital / Vetnetwork