New Patient Information General information about pet owner, pet and pet's health history. OWNER INFOPet Owner Name(Required) First Last Home Phone(Required)Cell Phone(Required)Would you like to receive reminders by text?(Required) Yes No Preferred Name Pronouns he she they Employer Work PhoneSpouse or Partner Name First Last PhonePreferred Name Pronouns he she they Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Would you like to receive reminders by email? Yes No EMERGENCY CONTACT INFOIn case of an emergency, and you cannot be reached, who should we contact?Name(Required) First Last Phone(Required)PET INFOPet's Name(Required) Species(Required)DogCatRabbitGuinea PigRodentFerretChinchillaOtherGender(Required)MaleFemaleNeutered MaleSpayed FemaleBreed(Required) Color(Required) Age and/or DOB(Required) PET HEALTH INFOIn order for us to provide the best care for your pet, please fill out the following information.Do you have pet insurance?(Required)YesNoInsurance Company Name What is the reason for the visit? When did your first notice the problem? If applicable, how did this occur?Have you observed any abnormal behaviors?When was your pet's last visit to the veterinarian? MM slash DD slash YYYY Who was the veterinarian who last examined your pet? What is the name of that facility? Are you doing oral care at home for your pet?i.e. brushing, rinsing, etc. Yes No How long have you had your pet? If applicable, what was the date and location of the last dental cleaning under anesthesia? What food is your pet currently eating?Have there been any changes in eating, drinking, or chewing? Yes No What treats and/or chew toys does your pet get? Please list all medications and/ or supplements that your pet is currently taking:Is your pet current on flea and tick prevention and heartworm prevention? Yes No Is your pet current with Rabies vaccine? Yes No When was the last Rabies vaccine?If unknown, please leave blank. MM slash DD slash YYYY Does your pet have any medical conditions?Has your pet had any reactions to previous anesthesia and/ or medications? Do you have any other questions or concerns that your would like to discuss with the doctor during the appointment?REFERRAL INFOI was referred by Primary Care Veterinarian Self Referral Friend Family Member My primary care veterinarian: Reason for referral