New Patient Questionnaire | Happy Tails Holistic Veterinary Care

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Complete this NEW PATIENT QUESTIONNAIRE if you are scheduling an appointment for a pet we have not seen previously. Please contact us if you have any questions.

Name*

First Last

Pet's Name

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

How did you hear about us?*

Email*

Date of Birth*

Weight*

Species*

Canine
Feline

Breed*

Sex (Male/Female and if Spayed or Neutered)*

Male
Female
Spayed
Neutered

Color*

Photo of your Pet*

Max. file size: 256 MB.

I agree to allow my pet(s) image to be used for marketing and/or educational purposes. No medical or personal information will be shared.

Please list the friend name that referred us

What type of veterinary treatment and recommendations are you looking for:*

Services Requested*

Preferred Appointment Day*

Preferred Appointment Time*

Morning
Afternoon

Appointment Comments

List all of your concerns for the doctor exam and treatment plan:*

A history of seizures, major diagnoses and/or surgeries:*

What is your pet’s current diet?

Kibble
Canned Food
Raw Diet
Home Cooked
Freeze Dried
Dehydrated

Brand / Details

Current medications/supplements, and how much of each you’re giving (indicate if refills are needed):*

Are you giving heartworm & flea/tick prevention as directed?*

A description of daily activity, and general exercise regimen:*

Are vaccinations and lab work current? Please list dates of most recent Rabies, Fecal and Heartworm test?:*

List microchip ID or mention if you’d like one implanted for your pet:*

Are there any services like acupuncture/ chiropractic care/ laser/ ozone, or vitamin /glucosamine therapies that you’d like for us to proceed with during your pet’s appointment?*

Would you like your pet to have an ear cleaning, nail trim, or anal sac expression during their visit?

Ear Cleaning
Nail Trim
Anal Sac Expression

Would you like to have an extended consultation with the DVM regarding diet or OTC supplements for an additional $35?

Yes
No

Which practice(s) should we expect your pet's complete medical records with doctor notes, labs, xrays, etc.?*

Please upload all of your referring veterinary records including doctors notes, blood work and X-rays.

* We are unable to accept any paper records at the time of the appointment. Please scan and email records to happytailsvetinfo@gmail.com, attach to this form, or have your veterinarian email them to us directly

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 10 MB.

Please note:

We require a non-refundable deposit of $60.00 per pet upon booking a new patient appointment.

This deposit is deducted from the cost of your initial exam and consultation ($120); it is not in addition to the cost of the visit. These first visits run 30-45 minutes long, additional consultation time is $35.70 *This is to ensure all patients are cared for in a timely manner and we can schedule staff appropriately.

We have a policy of 48-hour notice for cancelling or rescheduling. Your deposit will function as a cancelation fee if the cancelation/rescheduling occurs within 48-hours of the appointment time.

A 20% service fee will be taken if a refund is requested for any service.

We accept payments by cash, credit cards, and checks. Credit cards do encrue a 3.5% service fee from the POS.

Please have all of your pet's medical records sent to us at happytailsvetinfo@gmail.com.

Please explicitly ask the veterinary practices to send doctor notes, labwork, xray/ultrasound images, etc.

Veterinary Services Waiver and Release of Liability

1. Acknowledgment of Risks
I, the undersigned, understand that veterinary care involves certain risks, including but not limited to, anesthesia complications, reactions to medications, and unpredictable medical outcomes. I acknowledge that I am aware of these risks and have had the opportunity to ask questions regarding them.

2. Release of Liability
I agree to release and hold harmless Happy Tails Holistic Veterinary Care, its veterinarians, staff, and affiliates, from any and all liability, claims, damages, and losses related to the care and treatment of my pet.

3. Consent to Treatment
I authorize the veterinarians and staff at Happy Tails Holistic Veterinary Care to provide medical care, including diagnostic procedures, surgeries, and any necessary treatments for my pet. I understand Happy Tails Holistic Veterinary Care has trained staff to restrain my pet(s). If my pet is overly anxious or fractious, I understand that medications (oral or injectable) may be suggested to calm my pet(s) for treatment plans to be performed. Estimates will be provided prior to recommended treatment.

4. Refills
Please note that refill requests may take up to 48-72 business hours to be submitted, approved by the DVM and filled by the technician. All patients must have been seen within 6-12 months for recurring medication refills depending on their condition.

5. Technician Appointments
I understand that if I have a technician appointment my pet(s) will be taken to the treatment area and then retumed to me in the lobby. Technicians are not able to diagnose or treat an illness, as this would have to become a DVM exam.

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