Client's Name *

First

Last

Email *

With your e-mail address you will be able to:
• Check your pets' vaccination status
• Request appointments and boarding
• Purchase medication and food refills
• Inform us when pets are lost or deceased
• Notify us of address changes

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

I consent to receive SMS text messages from Gardner Animal Care Center. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Emergency/Alternate Phone

Spouse/Partner

Spouse/Partner Phone

Please list all pets that should be active on your account. Only list pets that currently live in your household. Please include each pet's name, species, breed, sex, if they are fixed, color, and age.

Pet #1 Name

Pet #1 Species

Pet #1 Breed

Pet #1 Sex

Male
Male - Neutered
Female
Female - Spayed

Pet #1 Color

Pet #1 Age/Birthday

Is your pet on any medications?

No
Yes

Medication Name

How much medication are they given?

How often is the medication given?

Date of last dose given?

Brand of food given?

How much food is given per feeding?

How many times a day are they fed?

What heartworm preventative do you give your pet?

When was the last dose given?

Do you have another pet to add?

No
Yes

Pet #2 Name

Pet #2 Species

Pet #2 Breed

Pet #2 Sex

Male
Male - Neutered
Female
Female - Spayed

Pet #2 Color

Pet #2 Age/Birthday

Is your pet on any medications?

No
Yes

Medication Name

How much medication are they given?

How often is the medication given?

Date of last dose given?

Brand of food given?

How much food is given per feeding?

How many times a day are they fed?

What heartworm preventative do you give your pet?

When was the last dose given?

Do you have another pet to add?

No
Yes

Pet #3 Name

Pet #3 Species

Pet #3 Breed

Pet #3 Sex

Male
Male - Neutered
Female
Female - Spayed

Pet #3 Color

Pet #3 Age/Birthday

Is your pet on any medications?

No
Yes

Medication Name

How much medication are they given?

How often is the medication given?

Date of last dose given?

Brand of food given?

How much food is given per feeding?

How many times a day are they fed?

What heartworm preventative do you give your pet?

When was the last dose given?

Which pet(s) is this appointment for?

Please select any canine vaccines your pet will be needing:

Please select any feline vaccines your pet will be needing:

Rabies
FVRCP-C
Feline Leukemia

Diagnostics needed:

Any other services needed?

Please indicate any medical concerns or changes in behaviors you’ve noticed since their last exam.

What other concerns or issues do you want to make sure the Doctor addresses, examines or discusses with you during the exam?

Please indicate below all medications your pet is currently taking, this includes prescribed medications, supplements, preventatives as well as over the counter products. Please include Name of Medication, Dosage, Frequency, Last Dose Given, Purpose of Medication. Example: Rimadyl, 25mg tab, 2 times/day, 6PM—1/30, Arthritis.

What prescription refills will your pet need during their visit?

If Other, please list what you need.

What type and size of food will you be needing?

Must be ordered by NOON on Monday to be delivered by Friday

Is this a new pet for your family?

Yes
No

If so, please indicate how long you’ve had them.

And, where did you get them?

If Other, please explain.

What food do you feed your pet?

How many times per day are they fed?

One
Two
Three
Four

And, how much are they fed AT EACH feeding?

If Other, please explain.

What kind of treats, snacks, table scraps and/or chews do you give your pet?

Does your pet have any sensitivities (activities, situations, or areas on the body)?

Yes
No

If so, please indicate what they are or what the triggers are:

Has your pet ever bitten anyone or other dogs?

Yes
No

Has your pet ever shown anxieties when visiting the Veterinarian?

Yes
No

Would you be interested in your pet receiving obedience training services?

Yes
No

Please indicate if your pet will be exposed to any of the following:

If Other, please explain.

Will your pet primarily be inside or outside?

Inside
Outside

How much of their time will be spent outdoors? (Please indicate time spent outside, i.e. two hours, most of the day, just for potty breaks)

Indicate the activity level that best suits your pet:

Very relaxed
Moderate
High Energy

What dental care do you provide your pet at home:

If Other, please explain.

Has your pet been seen by another Veterinarian or been to the Emergency Hospital since your last visit?

Yes
No

If Yes, please explain.

Are you receiving regular service reminders for your pet’s medical services?

Yes
No

We are now offering Wellness Plans, are you interested in learning more about our Wellness Plans?

Yes
No

For some of our Medical Progress Exams we offer Telemedicine visits with the Veterinarian. This service offers “FaceTime” or video chat with the Veterinarian, would you be interested in learning about that service?

Yes
No

Existing Client/Patient Form

Ready for a visit?

Have a question?

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