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Client Form – Multiple Pets

For all new and returning patients coming in for their yearly health exam. This form is for households bringing in two pets at the same time.

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Client Form – Multiple Pets

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 802-888-7776 for a faster response.

Updates on COVID-19 – Hospital Policies For All Appointments
*This form is required for all appointments with a doctor. Please fill this form out at your earliest convenience and at least 24 hours before your appointment.

Client Information

Name *

First

Last

Owner's Home Phone *

If you do not have one please put NA

Owner's Cell Phone *

If you do not have one please put NA

Email *

This is where your invoice will be sent after your visit.

Significant Other's Name

First

Last

Only if applicable

Significant Other's Cell Phone

Only if applicable

Significant Other's Email

Only if applicable

Current Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

How do you prefer to get your appointment reminders? *

Phone
Email
Text

Please select all that apply

What places is it ok for us to release your pet's medical records to? *

Other Vets
Daycares
Boarders
Groomers
Rescue Shelters
Town Offices
Insurance Companies
None

Please select all that apply

Please list anyone else (not listed above) you would like to give permission to bring your pet/s in. Be sure to include anyone who may watch your pet/s while you are away.

Are you, or anyone that lives with your pet, exhibiting symptoms of COVID-19 (cough, shortness of breath, fever) or has tested positive for COVID-19? *

PLEASE CALL TO RESCHEDULE 802-888-7776

Can we take a picture of your pet/s? *

Patient Information (1st Pet)

Name *

Breed *

Age or DOB *

Color *

Sex *

Male
Female

Does your pet have a microchip? *

Yes
No
Unknown

Does your pet have health insurance? *

Yes
No
Unknown

Patient Medical Background

If your pet is having diarrhea please bring a fresh fecal sample (no older than 24hrs and needs to be refrigerated if you are not coming right in with it).

If your pet is having urine issues please bring a fresh urine sample (no older than 24hrs old and needs to be refrigerated if you are not coming right in with it).

If your pet is has been vomiting please collect a sample of vomitus for review by the doctor.

Have you noticed any of the following? *

Coughing / Sneezing / Nasal Discharge
Vomiting / Diarrhea
Lameness / Pain / Difficulty standing, playing, and or jumping
Skin / Ear Irritation
Lumps / Bumps
Urine issues
Appetite / Weight Changes
Behavioral Changes (Lethargy / Ataxia)
Trauma / Body injury
Other
None - My Pet is healthy

Patient Information (2nd Pet)

Name *

Breed *

Age or DOB *

Color *

Sex *

Male
Female

Does your pet have a microchip? *

Yes
No
Unknown

Does your pet have health insurance? *

Yes
No
Unknown

Patient Medical Background

If your pet is having diarrhea please bring a fresh fecal sample (no older than 24hrs and needs to be refrigerated if you are not coming right in with it).

If your pet is having urine issues please bring a fresh urine sample (no older than 24hrs old and needs to be refrigerated if you are not coming right in with it).

If your pet is has been vomiting please collect a sample of vomitus for review by the doctor.

Have you noticed any of the following? *

Coughing / Sneezing / Nasal Discharge
Vomiting / Diarrhea
Lameness / Pain / Difficulty standing, playing, and or jumping
Skin / Ear Irritation
Lumps / Bumps
Urine issues
Appetite / Weight Changes
Behavioral Changes (Lethargy / Ataxia)
Trauma / Body injury
Other
None - My Pet is healthy

Additional Pet Health Questions

Is it ok for your pets to have treats and/or peanut butter during the appointment?

Do either of your pets have any known allergies? If yes, please list them.

Please put NA if the answer is no.

Would you like your pets to have nail trims while here? *

Additional rates may apply

Do you need any medications, supplements, and/or preventatives? *

Please list any medications, supplements, or preventatives your pet is currently taking. *

Is it a challenge to medicate your pet? *

Yes
No
Unsure

What type of food do you currently feed your pet? *

How much do you feed your pet and how often during the day? *

Ready for a visit?

We proudly serve the pets of Morrisville, Stowe, Waterbury, Jericho, Montpelier, and surrounding areas. We look forward to seeing you and your pet! You may call to book an appointment by clicking the button below.

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