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. 1 Pet Owner Information2 Pet Information3 Payment Policy4 Pet Photo Consent Pet Owner InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail* How did you hear about us?OnlineNewspaperHospital SignSocial MediaPersonal ReferenceWho may we thank for referring you? Pet InformationName*Age*For pets younger than 1 type 0Species*BreedColorSex*MaleFemaleSpayed / Neutered*YesNoIs your pet current on all vaccinations?*YesNoWhich clinic did they receive vaccinations at?Is your pet on heartworm prevention?*HeartgardRevolutionWhat type of flea control do you use on your pet?*FrontlineNexgardRevolutionHas your pet been passing worms?*YesNoPlease DescribeAny injury or illness in the past 30 days?*YesNoPlease DescribeDoes your pet have a history of having seizures?*YesNoIs your pet currently on any medications?*YesNoIf so, List medication name and dosage: Is your pet allergic to any medications/drugs?*YesNoIf so, what kind? What food is your pet currently eating?Are there any food intolerances/ allergies?*YesNoIf 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?*YesNoType of hair loss*PatchyGeneralizedExcessive SheddingIs your pet scooting?*YesNoIn the past 30 days, how is your pet’s appetite?*NormalIncreasedDecreasedIn the past 30 days, have you noticed any of the following with your pet’s weight?*StableLosingGainingHave you noticed a change in water consumption?*NormalIncreasedDecreasedHave your pet’s bowel movements been:*NormalDiarrheaConstipatedIs your pet’s urination:*NormalIncreased FrequencyIncreased AmountIs your pet straining to urinate?*YesNoDoes your pet have any lumps or bumps?*YesNoLocation of lumpsDoes your pet have bad breath?*YesNoHas your pet had a dental?*YesNoDate of last dental Date Format: 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?*YesNoPlease describeDo you have any other concerns?*YesNoPlease 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*Drivers License NumberState AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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
