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New Client Registration Form
To ensure the best care possible for your pet, please take the time to complete this form so we have as much information as possible. When done, click submit to send the form information to us.
Owner's Name
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Cell Phone
*
Home Phone
Email
*
Enter Email
Confirm Email
Spouse/Partner Name
First
Last
Spouse/Partner Cell Phone
Emergency Contact
Emergency Contact Name (if other than spouse)
Emergency Conact's Relation to You
parent, friend, etc...
Emergency Contact's Phone
Is this person authorized to make decisions about your pet’s health?
Yes
No
Were you referred to AV by one of our clients?
if so, by whom?
# of Pets in Your Household
#dogs, #cats, other...
How many pets are you registering (max. 5)
Pet #1 Information
Pet's Name
*
Species
*
Dog
Cat
Other
If other species, please specify
Breed (if known)
Color
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)
Pet Health History
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
Please check any symptoms or problems that you have noticed about your pet recently
Behavior Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye bulging or bloodshot
Gagging
Lack of Appetite
Lethargic Behavior
Limping
Loss of Balance
Scooting
Scratching Excessively
Shaking Excessively
Sneezing
Thirst and/or Urination Increase
Vomiting
Weakness
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Pet #2 Information
Pet's Name
*
Species
*
Dog
Cat
Other
If other species, please specify
Breed (if known)
Color
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)
Pet Health History
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
Please check any symptoms or problems that you have noticed about your pet recently
Behavior Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye bulging or bloodshot
Gagging
Lack of Appetite
Lethargic Behavior
Limping
Loss of Balance
Scooting
Scratching Excessively
Shaking Excessively
Sneezing
Thirst and/or Urination Increase
Vomiting
Weakness
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Pet #3 Information
Pet's Name
*
Species
*
Dog
Cat
Other
If other species, please specify
Breed (if known)
Breed (if known)
Color
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)
Pet Health History
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Date of last vaccines (if known)
Date Format: MM slash DD slash YYYY
What vaccines were given at this time
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
Please check any symptoms or problems that you have noticed about your pet recently
Behavior Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye bulging or bloodshot
Gagging
Lack of Appetite
Lethargic Behavior
Limping
Loss of Balance
Scooting
Scratching Excessively
Shaking Excessively
Sneezing
Thirst and/or Urination Increase
Vomiting
Weakness
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Pet #4 Information
Pet's Name
*
Species
*
Dog
Cat
Other
If other species, please specify
Breed (if known)
Color
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)
Pet Health History
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Date of last vaccines (if known)
Date Format: MM slash DD slash YYYY
What vaccines were given at this time
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
Please check any symptoms or problems that you have noticed about your pet recently
Behavior Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye bulging or bloodshot
Gagging
Lack of Appetite
Lethargic Behavior
Limping
Loss of Balance
Scooting
Scratching Excessively
Shaking Excessively
Sneezing
Thirst and/or Urination Increase
Vomiting
Weakness
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Pet #5 Information
Pet's Name
*
Species
*
Dog
Cat
Other
If other species, please specify
Breed (if known)
Color
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)
Pet Health History
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Date of last vaccines (if known)
Date Format: MM slash DD slash YYYY
What vaccines were given at this time
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
Please check any symptoms or problems that you have noticed about your pet recently
Behavior Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye bulging or bloodshot
Gagging
Lack of Appetite
Lethargic Behavior
Limping
Loss of Balance
Scooting
Scratching Excessively
Shaking Excessively
Sneezing
Thirst and/or Urination Increase
Vomiting
Weakness
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Home
New Clients
Take A Tour
New Client Form
About Us
Meet Our Team
Employment Opportunities
Services
Wellness and Vaccination
Preventive Services
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Health Screening Tests
Pet Supplies
Pet Health
Pet Health Checker
Pet Health Library
How-To Videos
Pet Food Recalls
Product Recalls
News
Contact Us
Request Appointment
Online Forms
facebook