BECOME A CLIENT

Please fill out the form to become a new client with Eastern Pet Integrative Care (E.P.I.C.) Veterinary Hospital.








    YOUR INFORMATION

    Client Name*

     
     

    Spouse Name

     
     

    Address*

     
     
     

    Home Phone

     

    Cell Phone

     

    Email*

     

    Preferred Method of Contact

     

     

    YOUR PET’S INFORMATION

    Pet’s Name*

     

    Species*

     

    Breed*

     

    Color*

     

    Date of Birth* (MM/DD/YYYY)

     

    Sex*

     

    Has Your Pet been Spayed or Neutered?*

     
     

     

    MEDICAL HISTORY AND INFORMATION

    Pet’s Health Issues

     

    Current Medications

    Please Bring all Current Medications and Therapies With You.

     

    Any Homeopathy?

    YesNoNot Sure

     

    Any Allergies?

    YesNoNot Sure

     

    Is Your Pet Nervous at the Vet?

    Yes NervousNot Nervous

     

    We wish to get a complete medical history by contacting previous vets. Will you allow this?

    AllowedNot Allowed

     

    Previous Veterinarians Info (if applicable)

     
     
     

     

    OTHER

    We maintain confidentiality of file information, but we do enjoy sharing photos of our pets. Sometimes the people associated may be in the photo also. Would you allow us to share photos?

    AllowedNot Allowed

    Do multiple people have legal guardianship of this pet?

    YesNo

    List all other people that can make legal decisions regarding this pet’s care.

     
     

     

    FOR THE SAFETY OF ALL PETS, PLEASE HAVE YOUR PET RESTRAINED – IN A SECURE CARRIER OR ON A SECURE LEASH.


    © 2021 Eastern Pet Integrative Care (E.P.I.C.) Veterinary Hospital. All rights reserved.