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info@dogwoodparkclinic.com
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Thank you for giving Dogwood Park Animal Clinic the opportunity to care for your
pet(s).
APPOINTMENT
7
To ensure the best care possible, please fill out this form completely.
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Owner's Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
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Connecticut
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District of Columbia
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
Cell Phone
Which number is best to reach you?
*
Home
Cell
Can you receive text messages?
*
Yes
No
Email
*
Add a Co-Owner?
*
Yes
No
Name
*
First
Last
Home Phone
Cell Phone
Previous Vet
Previous Vet's Phone Number
Whom should we thank for referring you?
PET HEALTH HISTORY
Pet's Name
*
Sex
*
Male
Female
Neutered/Spayed?
*
Yes
No
Breed
*
Color
*
Birthdate or Age
*
Current Medications
Please bring and give any medical records/vaccine records to the receptionists to make copies.
DIET AND ENVIRONMENT
What food does patient currently eat?
*
Amount and frequency?
*
Is your pet on any dietary supplements?
*
Yes
No
If so, what kind and what dosage?
*
Does your pet consume table food?
*
Yes
No
Please explain:
*
Is your pet primarily indoor or outdoor?
*
Indoor
Outdoor
Are there any other animals in the household?
*
Yes
No
Please describe:
*
Do you have your pet groomed or boarded outside of your home?
*
Yes
No
If so, how often?
*
Do you travel outside of Georgia with your pet?
*
Yes
No
If so, where?
*
PAST HISTORY
Has your pet had any prior illnesses, accidents, or surgeries?
*
Yes
No
Please explain:
Is your pet aggressive or fearful around strangers?
*
Yes
No
Please explain:
*
Is your pet on heartworm or flea/tick preventatives?
*
Yes
No
How frequently?
*
Year-round
Seasonally
Please list any other medications or supplements your pet receives:
Does your pet have any known allergies to any medications?
*
Yes
No
If yes, please list:
*
Has your pet ever had a reaction to any vaccines?
*
Yes
No
If yes, please list and explain:
*
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal.
*
I have read and agree.
I understand that payment is ALWAYS DUE IN FULL at time of service. A deposit of 50% of the treatment plan may be required before treatments or hospitalization of your pet. I recognize that financial concerns should be discussed PRIOR to examination and treatment.
*
I have read and agree.
Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media?
*
Yes
No
I authorize my emergency contact (other than myself) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18.
*
I have read and agree
Emergency Contact
*
First
Last
Emergency Contact Phone
*
Clear Signature
Date
*
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