Please complete this New Patient Form-you'll receive a confirmation upon successful submission. Required Fields must have a response. We need to receive this form at least 4 hours prior to your appointment.
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My appointment is scheduled for: (required)
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(required)
Mr.
Mrs.
Ms.
Dr.
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Children (ages)
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E-Mail Address- Owner #1 (required) :
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Please confirm E-Mail Address :
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County (required)
DuPage
Cook
Will
Lake
Kane
Other
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Work Telephone number
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Occupation & Title
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Work Telephone number
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Occupation & Title
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How did you become aware of our hospital? (required)
(Please check one)
Website
Hospital Sign
Facebook
Google
Other/previous Pet Seen Here
Personal Recommendation
Other
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Other- Please specify:
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If Personal Recommendation, whom may we thank?
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So that we are better able to understand the bond you have with your pet, please take a moment to answer the following three questions: |
Question 1
a. I feel that my pet is another member of our family
b. I feel that my pet is just a pet
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Question 2
a. I want the best medical care available for my pet: please recommend anything that you feel is necessary for good health
b. I want good medical care for my pet, but there is a limit to what I am able to have done
c. I want to perform only the services that I request
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Question 3
a. I want to learn as much as I can about pet health care- please explain in detail what has been done for my pet or what is needed
b. I would prefer you just summarize what has been done for my pet or what is needed
c. I want my pet to be healthy, but don't need to know what has been done
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Is your pet covered by any sort of Pet Health Insurance?
Yes
No
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How old was your pet when you acquired it? (required)
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How long have you had your pet? (required)
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Where did you acquire your pet?
Pet Shop
Private Home
Breeder
Humane Society/Shelter
Other
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Please complete the following questions so we can better understand your pet's lifestyle |
Is your pet ever boarded? (required)
Yes
No
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If yes, where?
Top Dog Retreat
Tail Gate
Camp BowWow
Dogtopia
Paradise 4 Paws
Other
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Is your pet ever groomed? If yes, where?
Does not go to a groomer
With Love From Head To Tail
Eclipse
Fresh Pals
Petco
private home
other
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How many dogs (total) are in your home?
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How many cats (total) are in your home?
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Any other pets in your home (please specify)?
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How many hours is your pet outside per day?
0 hour
0-1 hour
1-3 hours
3-8 hours
8-12 hours
12-24 hours
My pet only lives outdoors
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When outdoors, my pet
Roams free
Is on a leash
Loose, but under supervision
Fenced yard/enclosure
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PAYMENT POLICY |
All fees are due when services are provided or upon release of the patient- Cash, Checks, Visa, Mastercard and Discover are accepted forms of payment. Estimates are gladly provided upon request.
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By checking the box below, you acknowledge our payment policy and accept responsibility for all fees incurred. (required)
I acknowledge that payment is due upon completion of services and accept responsibility for payment of all fees.
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PET INFORMATION PROFILE |
Pet's Name (required)
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Species (required)
Dog
Cat
Other
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Breed: (required)
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Sex (required)
Male
Male neutered
Female
Female spayed (neutered)
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Date of Birth (please enter UNKNOWN if birthdate is unavailable) (required)
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Color (required)
Black
Brown
Tan
White
Grey
Red
Yellow
Orange
Other
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Markings (required)
solid
striped
mix
tabby
calico
tortoise
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Haircoat (required)
short
medium
long
curly
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Ears
erect
tipped
floppy
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Tail (required)
short
long
curly
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(for cats only) Is your cat declawed?
No
Yes- Front 2
Yes- All 4
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May we post an image of your pet on our Social Media pages (Facebook/Pinterest/Website)- pet's name and image only will be used- no last name will be used.
yes
no
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PET VACCINATION HISTORY |
Has your pet been vaccinated in the last 12 months? (required)
Yes
No
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Has your pet ever had an allergic reaction to any vaccines? (required)
Yes
No
I'm not sure
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Date of last Rabies vaccine:
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Date of last Fecal exam
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Canine Vaccines |
Date of last Canine Distemper/Parvo (DHPPv or DA2PPv)
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Date of last Canine Bordetella (kennel cough)
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Date of last Canine Leptospirosis
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Date of last Canine Influenza (H3N2 or CIV-2)
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Date of last Heartworm test
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Is your dog on heartworm preventative?
Yes- all year
Yes- seasonally
Yes- but only sporadically
No
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Feline Vaccines |
Date of last Feline Distemper (FVRCP)
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Date of last Feline Leukemia
:
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DIET AND MEDICAL HISTORY |
I feed my pet
Dry food
Semi-moist food
Canned food
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Is your pet allergic to any medications?
No
Yes (please specify below)
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My Pet is allergic to:
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Has your pet had any major illnesses? Please specify:
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Has your pet had any major surgeries? Please specify
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Date of your pet's last dental procedure
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Is there anything else that we should know about you or your pet? Thank you for taking the time to complete this form. Make sure you receive the confirmation message indicating successful submission of this form.
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Please email any prior records and vaccination history to info@DeVriesAnimalHospital.com or FAX to 630-833-5227. Please call us at 630-833-7387 if you have any questions. |
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