Please complete this New Patient Form at least 4 hours prior to your appointment- successful completion will generate the following message: "YOUR FORM HAS SUBMITTED SUCCESSFULLY"- Submission failure is usually related to incomplete "REQUIRED FIELDS". My appointment is scheduled for: (required)
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My pet is coming in for: (required) Wellness exam Illness Vaccine Newly Acquired Pet Other: (please elaborate under "Additional Information" at the end of this form Mr. Mrs. Ms. Dr.Children (ages) E-Mail Address- Owner #1 (required) : Please confirm E-Mail Address : County (required) DuPage Cook Will
Lake Kane OtherWork Telephone number Occupation & Title Work Telephone number Occupation & Title How did you become aware of our hospital? (required) (Please check one) Website Hospital Sign Facebook Google Other/previous Pet Seen Here Personal Recommendation OtherOther- Please specify: If Personal Recommendation, whom may we thank? 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 petQuestion 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 requestQuestion 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 doneIs your pet covered by any sort of Pet Health Insurance? Yes NoHow old was your pet when you acquired it? (required) How long have you had your pet? (required) Where did you acquire your pet? Pet Shop Private Home Breeder Humane Society/Shelter OtherPlease complete the following questions so we can better understand your pet's lifestyle
Is your pet ever boarded? Yes No If yes, where? Top Dog Retreat Tail Gate Camp BowWow Dogtopia Paradise 4 Paws OtherIs 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 otherHow many dogs (total) are in your home? How many cats (total) are in your home? Any other pets in your home (please specify)? 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 outdoorsWhen outdoors, my pet Roams free Is on a leash Loose, but under supervision Fenced yard/enclosurePAYMENT 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. 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.PET INFORMATION PROFILE
Pet's Name (required) Species (required) Dog Cat OtherBreed (if a mixed breed, please specify predominant breed): (required) Sex (required) Male Male neutered Female Female spayed (neutered)Date of Birth (please enter UNKNOWN if birthdate is unavailable) (required) Color (required) Black Brown Tan White Grey Red Yellow Orange OtherMarkings solid striped mix tabby calico tortoiseHaircoat short medium long curlyEars erect tipped floppyTail short long curlyDoes your pet have a microchip? (required) Yes No I don't knowWhat is your pet's Microchip number? (leave blank if unknown) (for cats only) Is your cat declawed? No Yes- Front 2 Yes- All 4May 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 noPET VACCINATION HISTORY
Has your pet been vaccinated in the last 12 months? (required) Yes NoHas your pet ever had an allergic reaction to any vaccines? (required) Yes No I'm not sureDate 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 NoFeline 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 foodIs your pet allergic to any medications? No Yes (please specify below)My Pet is allergic to: Has your pet had any major illnesses? Please specify: Has your pet had any major surgeries? Please specify 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. I plan to provide my pet's vaccine and/or medical records prior to my pet's appointment via: (required) Email (info@DeVriesAnimalHospital.com (PDF or Photo/JPEG are acceptable formats) via fax (630-833-5227) I will mail them I plan to drop them off in person prior to my appointment I do not have any vaccine or medical recordsThank you for completing this form- we look forward to meeting you and your pet!! Please call us at 630-833-7387 if you have any questions. Please look for the response that your form was submitted successfully!
SUCCESSFUL COMPLETION WILL GENERATE THE FOLLOWING MESSAGE: "YOUR FORM HAS SUBMITTED SUCCESSFULLY"- Submission failure is usually related to incomplete "REQUIRED FIELDS". PLEASE BE SURE TO CHECK THE "reCAPCHA" BOX PRIOR TO CLICKING "SUBMIT THIS FORM"