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Client Information
Todays Date
*
MM slash DD slash YYYY
First Name
*
Last Name
*
Phone#
*
Spouse’s First Name
Spouse’s Last Name
Spouse’s Phone
Your DOB
*
Month
Day
Year
Home Address
*
City
*
State
*
Zip
*
Occupation
*
Employer
*
Work Phone
*
Email
*
Patient (Pet) Information
Pets Name
*
Pets Birthdate
*
Month
Day
Year
Pets Gender
*
Male
Female
Spayed/Neutered
*
Spayed
Neutered
None
Pet Breed
*
Pet Color
*
Pet Age
*
Second Pet
Pets Name
Pets Birthdate
Month
Day
Year
Pets Gender
Male
Female
Spayed/Neutered
Spayed
Neutered
None
Pet Breed
Pet Color
Pet Age
Please let us know if you have more pets than this in your household, that we should add to your account. Thanks!
How Did You Hear About Dorr Vet?
Internet Search
Referred by a friend / word of mouth
New Sign/Building
Facebook
Referring Clinic/Vet
Referred by Friend’s name
*
Referring Clinic/Vet Name
*
We will gladly prepare a written estimate for you on all services, please ask if not offered. ALL FEES ARE DUE AT THE TIME OF SERVICE. We accept all major credit cards, personal checks, cash and CARE CREDIT. Please ask if you would like to know more about payment options with CARE CREDIT. There is a returned check fee on all NSF checks written. We charge a $25 NO SHOW FEE for every offense, we just ask for a 24 hour courtesy call when possible to cancel an appointment.
Pet History
Pet’s Name For Today’s Visit
*
Is your pet new to your home this month or year?
*
This Month
This Year
Before This Year
Was your pet coming from a breeder, a shelter or another family?
*
Breeder
Shelter
Another Family
Is this your first dog/cat?
*
Yes
No
Do you have a stool sample collected for today?
*
Yes
No
90% of Puppies are born with roundworms. It’s good to check this annually.
What brand of food are you currently using?
*
Do you plan for your pet to be indoor or outdoor only?
*
Indoor Only
Outdoor Only
Both
Has your pet had previous vaccines?
*
Yes
No
Do you have record of them?
*
Yes
No
Do you plan to microchip your pet at some point?
*
Yes
No
Will you be needing to board your pet at a facility or have them groomed? Attend training classes, dog parks or daycare programs?
*
Yes
No
Will you need to:
Board your pet at a facility
Have them groomed
Attend training classes
Dog parks
Daycare programs
Are there other cats or dogs in your home?
*
Cats
Dogs
Both
Neither
Are there human children in your home?
*
Yes
No
Do you plan to spay or neuter this pet, or will they be used for breeding?
*
Spay or Neuter
Used for Breeding
Other
Are you familiar with the following pet owner topics?
Deworming
Dental Care
Flea and Tick Monthly or quarterly Prevention Doses
Heartworm Prevention, yearly or monthly dosing
Regular Nail Trims
Anal Gland Expressions
Lyme Vaccine
Canine Influenza Vaccine
Feline AIDS and Leukemia disease/ testing/ vaccines
Do you have any questions about the specific breed of your pet and what to expect?
Signature of Legal Adult Responsible for Pet(s)
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3752 18th Street Dorr, MI 49323
269-793-7387
molly@dorrvetclinic.com
3752 18th Street Dorr, MI 49323
269-793-7387
molly@dorrvetclinic.com
3752 18th Street Dorr, MI 49323269-793-7387molly@dorrvetclinic.com