Welcome Form for New Clients

* indicates required field

Name:*

Street Address:*

City, state, zip:*

Home phone

Mobile Phone:

Email:*

How may be best contact you?

Place of Employment:

Work Phone:

May we contact you at work?

yes
no

How did you hear about Bern-Sabetha Veterinary Clinic?

If a friend, yellow pages directory or other, please specify

Is there anybody else who is authorized to make decisions regarding your pet?

yes
no

If yes, name:

How may we contact them?

Please list an Emergency Contact if we are unable to reach you:

How do you view your pet(s)?

Like a family member, I am concerned about all health issues.
Simply as a pet, not as concerned about all health issues.

Will you be providing medical records or would you like us to request a copy of your pet’s medical records from your previous veterinarian?

I will provide
Please call
No

Previous Veterinarian:

Pet Information - Pet Name:

Species

Dog
Cat
Other

If other Species please specify:

Breed:

Sex:

Male
Female

Date of Birth:

Neutered/Spayed?

Yes
No

Microchipped?

Do you have any other pets in your home?

Does your pet have any prior illnesses or injuries we should know about?

Have you medicated your pet recently? (including over the counter drugs)

Where did you get your pet?

How long have you owned your pet?

On average, how many hours a day is your pet outside?

How often do you bathe your pet?

What brand food does your pet eat?

Where does your pet sleep?

Select All Statements that Apply:

Select All Symptoms that are a Problem:

Any Other Symptoms:

Please list any other concerns or questions you may have that we can answer for you:

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