New Client / Patient Pet Owner New Client / Patient Pet Owner Client Information:First and Last Name:Employer:Spouse / Co-Owner:Address :Primary Contact Name & Telephone:Secondary Contact Name & Telephone:Email: What is your preferred method of contact: Phone Call Text Message Email Method of Payment for today’s services: Cash Check Visa/MC/Discover/American Express Care Credit Pet Health History:Pet Name:please Select Dog Cat Other Breed:Color:Birthdate:Sex: Male Male Neutered Female Female Spayed Date of most recent vaccinations:What is the Primary Reason for your pet's visit?*If your pet is experiencing any of the following symptoms, please check all that apply: Vomiting Diarrhea Constipation Increased Appetite Decreased Appetite Abnormal Urination Increased Drinking Decreased Drinking Lethargy Lameness Change in Behavior Crying or Whimpering Excessive Panting Coughing, Wheezing, Choking, or Gagging Sneezing Tremors or Seizures If you checked any of the symptoms above, please provide more detail (how long, frequency, etc).:If your pet is experiencing any of the following symptoms, please check all that apply: Shaking head or Ear odor Scooting rear Hair Loss Rash Itching or Scratching Lumps or Bumps Unusual Discharge If you checked any of the symptoms above, please provide more detail (how long, frequency, location, etc).:Please list all medications your pet is currently receiving. Please include all prescription and over the counter medications:What is your pet's current diet? Brand and type of food? Amount of treats given a day?:Date: Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.