Patient Information

Client Name *

Client Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Name *

Primary # *

Secondary #

Email *

Species *

Canine
Feline

Sex of the patient *

Male
Female

Is the patient spayed/neutered? *

Yes
No

Breed *

Patient's Date of Birth *

Name of Previous Hospital

Name of Previous Hospital #

Has your pet been to a veterinarian in the past 3 years? *

Yes
No

Has your pet had any reactions to vaccines in the past? *

Yes
No

If yes, which one(s)?

Any allergies to medications? *

Yes
No

If yes, which one(s)?

Has your pet had surgeries other than spay/neuter? *

Yes
No

If so, for what? (foreign body, orthopedic, other)

Is your pet on any medication and/or supplements? *

Yes
No

Please list all:

Are there any medical conditions we should be aware of? *

Yes
No

Please list all:

Has your pet displayed any characteristics of anxiety? *

Yes
No

If so, please explain:

With previous veterinarians has your pet required sedation, muzzling, or special handling? *

Yes
No

If so, please explain:

Do we have permission to use pictures, history, or medical information about your pets in the media? i.e. print materials, our website, or our social media platforms? *

Yes
No

How did you hear about us? *

Search engine (Google, Yahoo, etc.)
Recommended by friend or colleague
Social media
Other

(Other) Please Specify: *

*Proof of rabies vaccination is required before time of appointment. If the patient is not vaccinated for rabies and deemed healthy, vaccination will be given during appointment at the cost of the owner. Per the Ohio Revised Code 505.11, all cats and dogs are required to be vaccinated against the Rabies virus. ** The Animal Hospital of Delhi Hills uses low stress handling, in order to decrease the stress of our patients and for the safety of our staff. Sometimes this may require us to reschedule your pet so they can have sedation on board and/or muzzle training. It is up to our discretion what we would recommend for your pet.

I filled out the questionnaire to the best of my knowledge and believe that the answers above are accurate. I consent to the Animal Hospital of Delhi Hills obtaining my pet’s previous records. *

Yes
No

Signature of Owner *

New Client Patient Intake

New Client Patient Intake Form

Patient Information

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Hours