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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us?*FriendFacebookGoogleYelpReferring VeterinarianPrint AdLocationEmail* 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: 128 MB.Please list the friend name that referred us What type of veterinary treatment and recommendations are you looking for:*IntegrativeWestern MedicineHolistic / Natural Options ONLYServices Requested*Preferred Appointment Day* Monday Tuesday Wednesday Thursday Friday Preferred Appointment Time* Morning Afternoon Appointment Comments Type of Appointment Requested*Curbside - select if prefer to wait outside or in your car.Drop-Off - select if you prefer to drop-off your pet for the day or for a few hours.In-person - select if you prefer to be in the room with your pet for the examination.*At this time we are not accepting in-person appointments due to the increase in the pandemic*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 Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB. Please note: We require a deposit of $57.68 per pet upon booking a new patient appointment. This deposit is deducted from the cost of your visit; it is not in addition to the cost of the visit. We have a policy of 48-hour notice for cancelation 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. We accept payments by cash, credit cards, checks and Venmo (@Drjulia-Happytails). 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. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
