Welcome to Ibis Animal Hospital!
Thank you for giving us the opportunity to care for your pet(s). We're happy to answer any questions you may have about their health. To ensure the best care possible, please take the time to fill this form out completely.
Today's Date:
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Month
-
Day
Year
Client Name
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First Name
Last Name
Your Birthdate
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Month
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Day
Year
Which pronouns do you prefer?
Him
He
Her
She
They/Them
Email
example@example.com
Cell Phone Number:
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Area Code
Phone Number
E-mail
*
example@example.com
Spouse's Name
First Name
Last Name
Their Birthdate
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Month
-
Day
Year
Which pronouns do they prefer?
Him
He
Her
She
They/Them
Cell Phone Number:
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Area Code
Phone Number
E-mail
example@example.com
Home Address
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Street Address
City
State
Zip Code
How did you hear about Ibis Animal Hospital?
Our Website
Facebook
Saw our Sign in the Plaza
Google
Did you hear about us from a friend, family member, animal rescue, or other business? If you did, please let us know so we can thank them for introducing us!
Please add a full name or staff member's name if you can. Thank You!
We LOVE to know what makes our clients happy! What are your interests and hobbies? We just want to get to know you a bit better. Thanks so much!
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For your conveniece, we can place a credit card on file in order to ensure that the check-out process after your visits are much faster. It also helps us to reduce unnecessary contact during COVID-19. We'll only use it for authorized charges & your information is always kept as securely as we treat our own. During future visits, you won't have to sign any receipts; you'll simply let us know to charge the card on file. We're happy to email you a receipt upon request.
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Sure, thanks for helping me check out faster!
No, thank you.
Pet # 1
Pet Name
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Gender?
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Male
Female
What Species is this Pet?
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Dog
Cat
Bird
Rabbit
Rodent
Other Exotic
Breed
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How Old is your Pet?
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If You're Unsure, a Rough Estimate is Fine.
What Color are They?
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Are they Spayed/Neutered?
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Yes
No
Unsure
Are they up to date on Vaccines? When are they due?
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When was your pet last seen by a vet?
This doesn’t need to be exact; just approximate.
Does your Pet have any Pre-Existing or Previously Known Medical Conditions?
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Is your Pet Currently on a Heart Worm Preventative?
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Yes
No
I'm Not Sure
If yes, Which is it?
Heartgard
Trifexis
Vectra
Revolution
ProHeart 6
ProHeart12
Other
Is your Pet Currently on a Flea/Tick Preventative?
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Yes
No
I'm Not Sure
If yes, Which is it?
Nexgard
Trifexis
Frontline
Comfortis
Sentinel
Credelio
Simparica
Bravecto
Advantix
Interceptor
Is your Pet Currently Taking any other medications?
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Yes
No
If They're Currently on any Medication(s), Please List It/Them Here:
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Please Describe your Pet's Diet as Accurately as Possible. (Include any Treats or Table Scraps.)
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ie: Fluffy gets 1 cup of Science Diet I/D Low Fat 2x/ day. He also gets Lean Treats.
Please Select any Symptoms or Problems that you've Noticed Recently:
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None at all. We're here for a Wellness Visit.
Behavior Issues
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Urinary Issues or Peeing in the House
Eye Bulging or Bloodshot
Gagging or Dry Heaving
Lack of Appetite
Increased Appetite
Limping
Loss of Balance
Scooting (rubbing their rear of the floor.)
Scratching/Biting at Skin or Feet
Seems Depressed
Shaking Head
Sneezing
Thirst and/or Urination Increased
Vomiting
Weakness
Is This the Only Pet That You’ll be Bringing to us for Pet Care?
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Yes
No
I have one or more additional pets, but I’m not sure yet if I’ll be bringing them here.
Change Info on Last Page
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Pet # 2
Pet Name
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Gender?
*
Male
Female
What Species is this Pet?
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Canine
Feline
Bird
Rabbit
Rodent
Other Exotic
Breed
*
How Old is your Pet?
*
What Color are They?
*
Are they Spayed/Neutered?
*
Yes
No
Are they up to date on Vaccines? When are they due?
*
When was your pet last seen by a vet?
This doesn’t need to be exact. A rough estimate is fine.
Does your Pet have any Pre-Existing or Previously Known Medical Conditions?
*
Is your Pet Currently on a Heart Worm Preventative?
*
Yes
No
I'm Not Sure
If yes, Which is it?
Heartgard
Trifexis
Vectra
Revolution
ProHeart 6
ProHeart12
Other
Is your Pet Currently on a Flea/Tick Preventative?
*
Yes
No
I'm Not Sure
If yes, Which is it?
Nexgard
Trifexis
Frontline
Comfortis
Sentinel
Credelio
Simparica
Bravecto
Advantix
Interceptor
Is your Pet Currently Taking any other medications?
*
Yes
No
If They're Currently on any Medication(s), Please List It/Them Here:
*
Please Describe your Pet's Diet as Accurately as Possible. (Include any Treats or Table Scraps.)
*
ie: Fluffy gets 1 cup of Science Diet I/D Low Fat 2x/ day. He also gets Lean Treats.
Please Select any Symptoms or Problems that you've Noticed Recently:
None at all. We're here for a Wellness Visit.
Behavior Issues
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye Bulging or Bloodshot
Urinary Issues or Peeing in the House
Gagging or Dry Heaving
Lack of Appetite
Increased Appetite
Limping
Loss of Balance
Scooting (rubbing their rear of the floor.)
Scratching/Biting at Skin or Feet
Seems Depressed
Shaking Head
Sneezing
Thirst and/or Urination Increased
Vomiting
Weakness
Back
Next
Consent & Authorization
At Ibis Animal Hospital, we love our patients & sometimes, we want to share a pup's cute face on our Facebook page or on one of our fliers. If it's alright with you, we'd like your permission to take photos of your adorable pet(s) for use on social media or fliers. Is that alright?
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Sure! My Pet is Super Photogenic.
No, but Thank You for Asking.
I hereby authorize the Veterinarian to examine, prescribe for, or treat, the pets that I've described in the New Patient Registration form. I understand that Ibis Animal Hospital requires current vaccinations except in cases determined by the veterinarian to no longer be medically appropriate. If the veterinarian determines that these vaccinations to not be up to date, I authorize Ibis Animal Hospital to administer them. If my canine(s) is found to have fleas during their visit, I authorize CapStar to be given in order to treat the fleas which are currently on my pet(s). I hereby state that I'm over 18 years of age, I am the owner (or authorized representative of the owner) and I have the authority to make both medical and financial decisions regarding this animal. I assume responsibility for all charges incurred in the care of the animal(s) listed on said form. I also understand & agree that these charges will be paid in full at the time services are rendered and prior to release of said pet(s). I also understand that a deposit may be required for certain medical or surgical treatments.
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