Dog New Patient Information Packet and Questionnaire

Florida Veterinary Behavior Service
Lisa Radosta DVM, DACVB

Krista Sirois DVM

Alison Gerken DVM

Megan Petroff DVM
Hello!
Thank you for making a behavioral medicine appointment for your pet. We have been providing specialty behaviorial medicine treatment to our patients in south Florida since 2007. Our team is committed to helping your pet overcome his or her behavior disorders.

In this packet, you will find the following items:

1. A registration form

2. Tips for your pet's appointment

3. A patient questionnaire

These forms will automatically submit to us when you submit online.

Please let us know what we can do to help you in the time leading up to your pet's appointment. You can find maps with our location information and direct numbers to those hospitals at our website:www.flvetbehavior.com.

We are looking forward to meeting you and your pet!

Sincerely,

The Florida Veterinary Behavior Service team
Please contact any primary care or specialty veterinarians who have treated your pet and request your pet's medical records be sent to our office so that they are received 3 days prior to your pet's appointment date. They can fax them to 561-795-8537 or email them to info@flvetbehavior.com. This is an important step for the complete evaluation of your pet's health. *

I understand

Florida Veterinary Behavior Service Registration Form and Waiver
Primary Pet Parent (your pet's medical record will be under this person)
Full Name

First Name Last Name
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
E-mail
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Secondary Pet Parent
Full Name

First Name Last Name
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
E-mail
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Would you like us to email you when new articles are uploaded onto our website? Emails are never shared with anyone!

Yes No
We may take pictures and videos as a part of your pet's appointment. Below is a consent form for use for images of your pet. When used, there will not no identifying information of the pet or yourself such as your name. Please consent below to whichever option works best for you.

My pet's pictures and videos are to be used only for my pet's medical record. My pet's pictures and videos can be used for my pet's medical record, textbooks, veterinary publications including journals, textbooks and electronic publications, veterinary presentations. Do not use my pet's picture for any purpose including in his or her medical records.
Who is your pet's primary care veterinarian? Please list the veterinarian, clinic name and phone.
Please list all veterinary hospitals (including the phone number) where your pet has been seen in the past 5 years.
Who referred you to the Florida Veterinary Behavior Service?
I am the owner(s) of the animal(s) seeking behaivoral medicine treatment from the Florida Veterinary Behavior Service. Behavioral treatment, training and advice when properly maintained after completion can be very helpful in resolving problem behaviors in aniamals. Because each pet is an individaul, no guarantee or assurance can be made as to the results that may be obtained. Animal behavior including aggresion is unpredictable and will remain unpredictable after its treatment. Florida Veterinary Behavior Service cannot promise that the animal's Behavior Service treatment, training or advice will completely eliminate the animal's potential danger to persons or completely control the animal's aggressiveness. Animals should be closely supervised particularly around children and infants and should be controlled at all times including conformance with local ordinances and "leash laws."

I am bringing my pet to this appointment with a full knowledge of these risks and understand and accept the liability that is inherent in owning a pet who has shown aggressive behavior.

I understand that all fees are to be paid at the time of service and accept full responsibility for the charges incurred in the treatment of my pet
Primary Pet Parent's Signature (use your cursor to sign)
SecondaryPet Parent's Signature (use your cursor to sign)
If at least one pet parent listed above will not be physically present at your pet's appointment, please list below the person(s) with whom we are authorized to speak. We cannot speak with anyone about your pet's care outside of the pet parents listed above and your pet's primary care veterinarian without written authorization.
Pet Parent's Signature (use your cursor to sign)

Helpful Hints...
Videos can be very helpful when assessing a pet's behavior patterns. Please send videos of your pet's environment and the behavior problem itself to us at the email above. If the video is too large to send it by email, please upload it to Youtube or Dropbox and send us a link. Do not under any circumstances provoke aggressive behavior in order to get us a video.

Bring all pets that are involved in the problem to the appointment if you can do so safely. If your other pets are not involved directly in the problem for which you are seeking help, it is better for you to leave them at home so that we can concentrate solely on the pet who needs help.

Bring your pet's favorite toys and treats with you to the appointment in case we treat your pets on that day or we can use those items during your pet's appointment.

Sleep Behaviors
Does your pet sleep through the night?

Yes No
Have you noticed any change in your pet’s sleeping patterns in the past 3 months?

Yes No
Does your pet take naps during the day when you are home?

Yes No

Cancellation Policy
Please initial in each box below as acknowledgement of the FVBS cancellation policy.
$20 fee applied to your account if appointments are cancelled with less than 24 hours notice. *
$40 fee applied to your account if no notice (no show) for a missed appointment. *
$50 fee applied to your account if no notice (no show) for a missed appointment more than one time. *

Have pictures or videos to upload?

Upload videos and pictures directly to our DropBox by clicking here.

You can also email photos/videos to info@flvetbehavior.com.
When you have completed the entire questionaire form, click submit.
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Florida Veterinary Behavior Service

Florida Veterinary Behavior Service Registration Form and Waiver

Helpful Hints...

Dog Behavioral Questionnaire

Cancellation Policy

Cognitive Dysfunction Screen