NEW PATIENT INFORMATION

Your Name*

Your Phone Number*

Your Email Address*

Patient's Name*

Patient's Birthday

Or Patient's Age

Species*
DogCat

Sex*
MaleFemale

Color*

Breed*

Microchip #

Name of Pet Insurance Company

Would you consider your pet:*
Strictly InsideOutside Only to Urinate/DefecateBoth Indoor and OutdoorStrictly Outdoor

If your pet is currently taking any of the following medications, please list below:

Heartworm Prevention

Flea Prevention

Other

Please answer yes/no and explain any details below if needed. Is your animal:

Coughing
YesNo

Sneezing
YesNo

Drinking Excessively
YesNo

Urinating Excessively
YesNo

Vomiting
YesNo

Having Diarrhea or Soft Stools
YesNo

Does your pet have any allergies?
YesNo

If yes, what are they allergic to?

Amplifying information for the above (if necessary):

Please list all brands of food you are currently feeding (canned / dry / treats / table scraps / etc):*

Does your animal have any chronic or ongoing issues that we should be aware of prior to the exam?*

Please provide your previous veterinarian:

Can we contact your previous veterinarian for your pet's records?
YesNoN/A

We would like to make your animal’s visit as stress-free as possible. Can you please let us know if your animal has any preferences?

Prefers women
YesNo

Prefers men
YesNo

Fearful - may bite
YesNo

Fearful - will bite
YesNo

Shy - go slow
YesNo

Is better away from you
YesNo

Is food motivated
YesNo

Does well with restraint
YesNo

Please provide any pertinent history that we should be aware of prior to seeing your animal.

How did you find out about CoastView Veterinary Hospital?
YelpGoogleClient ReferralEmployee ReferralSDHSFacebookInstagram

Client Referral's Name

Do you have a second pet?
YesNo

Patient's Name

Patient's Birthday

Or Patient's Age

Species
DogCat

Sex
MaleFemale

Color

Breed

Microchip #

Name of Pet Insurance Company

Would you consider your pet:
Strictly InsideOutside Only to Urinate/DefecateBoth Indoor and OutdoorStrictly Outdoor

If your pet is currently taking any of the following medications, please list below:

Heartworm Prevention

Flea Prevention

Other

Please answer yes/no and explain any details below if needed. Is your animal:

Coughing
YesNo

Sneezing
YesNo

Drinking Excessively
YesNo

Urinating Excessively
YesNo

Vomiting
YesNo

Having Diarrhea or Soft Stools
YesNo

Does your pet have any allergies?
YesNo

If yes, what are they allergic to?

Amplifying information for the above (if necessary):

Please list all brands of food you are currently feeding (canned / dry / treats / table scraps / etc):

Does your animal have any chronic or ongoing issues that we should be aware of prior to the exam?

Please provide your previous veterinarian:

Can we contact your previous veterinarian for your pet's records?
YesNoN/A

We would like to make your animal’s visit as stress-free as possible. Can you please let us know if your animal has any preferences?

Prefers women
YesNo

Prefers men
YesNo

Fearful - may bite
YesNo

Fearful - will bite
YesNo

Shy - go slow
YesNo

Is better away from you
YesNo

Is food motivated
YesNo

Does well with restraint
YesNo

Please provide any pertinent history that we should be aware of prior to seeing your animal.

Do you have a third pet?
YesNo

Patient's Name

Patient's Birthday

Or Patient's Age

Species
DogCat

Sex
MaleFemale

Color

Breed

Microchip #

Name of Pet Insurance Company

Would you consider your pet:
Strictly InsideOutside Only to Urinate/DefecateBoth Indoor and OutdoorStrictly Outdoor

If your pet is currently taking any of the following medications, please list below:

Heartworm Prevention

Flea Prevention

Other

Please answer yes/no and explain any details below if needed. Is your animal:

Coughing
YesNo

Sneezing
YesNo

Drinking Excessively
YesNo

Urinating Excessively
YesNo

Vomiting
YesNo

Having Diarrhea or Soft Stools
YesNo

Does your pet have any allergies?
YesNo

If yes, what are they allergic to?

Amplifying information for the above (if necessary):

Please list all brands of food you are currently feeding (canned / dry / treats / table scraps / etc):

Does your animal have any chronic or ongoing issues that we should be aware of prior to the exam?

Please provide your previous veterinarian:

Can we contact your previous veterinarian for your pet's records?
YesNoN/A

We would like to make your animal’s visit as stress-free as possible. Can you please let us know if your animal has any preferences?

Prefers women
YesNo

Prefers men
YesNo

Fearful - may bite
YesNo

Fearful - will bite
YesNo

Shy - go slow
YesNo

Is better away from you
YesNo

Is food motivated
YesNo

Does well with restraint
YesNo

Please provide any pertinent history that we should be aware of prior to seeing your animal.

Do you have a fourth pet?
YesNo

Patient's Name

Patient's Birthday

Or Patient's Age

Species
DogCat

Sex
MaleFemale

Color

Breed

Microchip #

Name of Pet Insurance Company

Would you consider your pet:
Strictly InsideOutside Only to Urinate/DefecateBoth Indoor and OutdoorStrictly Outdoor

If your pet is currently taking any of the following medications, please list below:

Heartworm Prevention

Flea Prevention

Other

Please answer yes/no and explain any details below if needed. Is your animal:

Coughing
YesNo

Sneezing
YesNo

Drinking Excessively
YesNo

Urinating Excessively
YesNo

Vomiting
YesNo

Having Diarrhea or Soft Stools
YesNo

Does your pet have any allergies?
YesNo

If yes, what are they allergic to?

Amplifying information for the above (if necessary):

Please list all brands of food you are currently feeding (canned / dry / treats / table scraps / etc):

Does your animal have any chronic or ongoing issues that we should be aware of prior to the exam?

Please provide your previous veterinarian:

Can we contact your previous veterinarian for your pet's records?
YesNoN/A

We would like to make your animal’s visit as stress-free as possible. Can you please let us know if your animal has any preferences?

Prefers women
YesNo

Prefers men
YesNo

Fearful - may bite
YesNo

Fearful - will bite
YesNo

Shy - go slow
YesNo

Is better away from you
YesNo

Is food motivated
YesNo

Does well with restraint
YesNo

Please provide any pertinent history that we should be aware of prior to seeing your animal.

We appreciate you taking the time to fill out our general questions.  We will likely have more questions upon your arrival.

A few things that are unique about our hospital:

  • We strive to create a minimal stress environment for you and your animal.
  • We ask that you help us create a friendly and motivated environment by withholding food the morning of the appointment.
  • Please don't be offended, but we will actually ignore your animal for the first few minutes of the exam process - just to minimize their stress.
  • We will do our best to help you and your pet have a good experience in our care.
  • If we are having difficulty with the exam, we will generally offer you options to decide if we will continue or reschedule at a later date to minimize stress.
  • We know this may be a different than other experiences you may have had, but we hope you will find this care to be better for you and your animals overall health.

We know you have many options in choosing care for your family and we appreciate having the opportunity to work with you.

Sincerely,
The CoastView Veterinary Hospital Family