HEAL New Patient Form Please tell us a little bit about you and your pet. You can fill out this form online, or if you prefer you can download a PDF version of the New Pet Information Form or New Client Information Form. New Client Information (Primary Pet Guardian/ Financially Responsible Party) End Section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Client Name: * Address: * City: * Zip Code: * Cell Phone: Work Phone: Home Phone: Primary e-mail address: * *Please note that our primary form of communication for appointment confirmations and reporting of test results is via email. Your employer: Your occupation: DL state of issue and number: How did you hear about HEAL? If someone referred you to HEAL, who should we thank? *If your regular veterinarian referred you to us for specific services, please complete or referred client paperwork. Has you pet been exposed to any type of immune system disorder? Yes No To offer comprehensive care and help support the bond between you and your, please note if you or anyone in your home, or to whom your pet is consistently exposed (extended family member or friend), has any type of immune system disorder. Immune system disorders may included, but are not limited to: Crohn's, Alcoholism, Cancer, etc. End Section Secondary Custodial Parent Information Name: * Address: * Contact phone number: * Contact e-mail End Section New Patient Information (Information about your pet) Your Pet's Name: Species: Dog Cat Breed: Date of Birth: Sex: Male Female Spayed or Neutered: Yes No Are there other pets in the home? Yes No If you checked yes above, please list type and age of pet Pet obtained at what age? From where? Is this pet a therapy or working pet? Yes No If you checked yes, what certification does your pet have? If you obtained your pet from a breeder, did his/her parents hold any health certifications? Yes No Not sure For example: OFA- good hips/ elbow, PRA clear, vWD clear, etc. If yes, please indicate certifications/ clearance and if sire or dam: For example: OFA- good hips/ elbow, PRA clear, vWD clear, etc. Does your pet have a microchip? Yes No Microchip ID#, if known Does your pet have any allergies to medications or vaccines? If so, please provide details: Chronic Medications with dosing and frequency: Example: Rimadyl 25mg Twice a day Supplements- for blended supplements, please give name and then itemize each active ingredient and mg of each given AND frequency: Please provide a timeline of your pet’s past medical history as best you can recall: What are your primary concerns/ goals for your pet? To best utilize your pet’s scheduled appointment time, we strongly encourage that all previous medical history, vaccination record, lab results, and x-ray images be sent to HEAL at least 48 hours prior to your appointment time. All items may be faxed to 214-723-7606 or emailed to info@healvet.com *Please reference and sign our Appointment Policy End Section
