Welcome to Traveling Tails Veterinary Clinic! Thank you for choosing us for your pet care needs. So that we may provide your pet with the best comprehensive and personalized care, please complete the forms below. 1Pet Owner Information2Pet Information3Payment Policy4Pet Photo Consent Pet Owner InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail* How did you hear about us? Online Newspaper Hospital Sign Social Media Personal Reference Location Preference*Thousand Oaks1604/i10Who may we thank for referring you? Pet InformationName* Age*For pets younger than 1 type 0Species* Breed Color Sex* Male Female Spayed / Neutered* Yes No Is your pet current on all vaccinations?* Yes No Which clinic did they receive vaccinations at? Is your pet on heartworm prevention?* Heartgard Revolution What type of flea control do you use on your pet?* Frontline Nexgard Revolution Has your pet been passing worms?* Yes No Please DescribeAny injury or illness in the past 30 days?* Yes No Please DescribeDoes your pet have a history of having seizures?* Yes No Is your pet currently on any medications?* Yes No If so, List medication name and dosage: Is your pet allergic to any medications/drugs?* Yes No If so, what kind? What food is your pet currently eating? Are there any food intolerances/ allergies?* Yes No If so, what? Has your pet hand any of the following symptoms in the past 30 days ?*Check all that apply None Vomiting Sneezing Gagging Shaking head Diarrhea Coughing Lethargic Scratching Any hair loss?* Yes No Type of hair loss* Patchy Generalized Excessive Shedding Is your pet scooting?* Yes No In the past 30 days, how is your pet’s appetite?* Normal Increased Decreased In the past 30 days, have you noticed any of the following with your pet’s weight?* Stable Losing Gaining Have you noticed a change in water consumption?* Normal Increased Decreased Have your pet’s bowel movements been:* Normal Diarrhea Constipated Is your pet’s urination:* Normal Increased Frequency Increased Amount Is your pet straining to urinate?* Yes No Does your pet have any lumps or bumps?* Yes No Location of lumps Does your pet have bad breath?* Yes No Has your pet had a dental?* Yes No Date of last dental MM slash DD slash YYYY Have you noticed any of the following in your pet? Lameness or Stiffness Difficulty rising after sitting Difficulty rising after sleeping Difficulty rising after exercise Which leg? Select All Front left Front right Back left Back right Have you noticed any behavioral changes in the last 30 days?* Yes No Please describeDo you have any other concerns?* Yes No Please Describe Payment PolicyPayment Policy*Payment for services must be paid in full at the time services are rendered or before your pet is released from the hospital. A 50% deposit is required before all hospitalizations. For your convenience, we honor personal checks (with proper identification), Debit, Visa, Master Card, Discover, American Express and Care Credit. Traveling Tails Veterinary Clinic can NOT extend credit. I understand and agree to the above payment policy*Signature* Reset signature Signature locked. Reset to sign again Drivers License NumberState AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Pet Photo ConsentConsent I grant permission to the followingI hereby grant Traveling Tails Veterinary Clinic permission to use any photographs taken of myself or my pet, in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become your property. I hereby authorize to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing your programs or for any other lawful purpose. In signing this consent, I give authorization to use my name and my pet’s name and information as printed below.Signature Reset signature Signature locked. Reset to sign again
