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New Client Form
Courtney DeWinter
2025-05-08T13:50:10+00:00
New Client Form
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*
" indicates required fields
New Client Form For Safe Harbor Animal Hospital SC
Name
*
First Name
Last Name
Primary Mobile Number
*
Please enter your email
*
example@example.com
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Secondary owner information
First Name
Last Name
Phone
Please enter a valid phone number.
Emergency
First Name
Last Name
Phone
Please enter a valid phone number.
Preferred contact mode
*
Email
Call
Text
How did you hear about us?
*
Social Media
Google Search
Drove By
Personal Referral
Rescue/AKC
Who referred you?
*
In the future, I may request that my pet’s consolidated medical information or entire medical chart be transferred elsewhere (kennel, groomer, daycare, another veterinarian, other). I understand that the medical chart is a legal document that may also contain sensitive information about me and by requesting the transfer of my pet’s medical record, I am authorizing the release of its contents. I hereby authorized the veterinarian to examine, prescribe for, and/or treat the animal(s) described on the following pages. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.
Animal hospitals
Animal hospitals of the lowcountry would like your permission to use images taken of your pet on our website and social media platforms. If you do not consent to have your pet’s picture used, please click this box.
Signature of responsible party
*
Sign Here
Date
*
MM slash DD slash YYYY
Pet Health History Pet Information
Name
*
Breed
*
Birthdate
*
MM slash DD slash YYYY
Color
*
Sex
*
Male
Female
Male Neutered
Female Spayed
Previous Veterinarian
Previous Veterinarian
*
Purpose of last visit
*
Date of last visit
*
MM slash DD slash YYYY
Date of last vaccines
*
MM slash DD slash YYYY
Has your pet ever been sick after receiving vaccinations?
*
Is your pet on heartworm prevention?
*
Yes
No
Product Name
Date of last dose given
MM slash DD slash YYYY
Is your pet on flea and tick prevention?
*
Yes
No
Product Name
Date of last dose given
MM slash DD slash YYYY
Is your pet currently taking any long term medications?
*
Yes
No
If yes, please list
What foods are you currently feeding your pet? please list all sources, brands, and treats
*
Does your pet have a history of ear infections, skin infections, or hairloss?
*
Has your pet ever experienced a serious illness or disease?
*
Has your pet ever been diagnosed with any of the following conditions?
*
Adrenal gland disease
Diabetes
Heartworm disease
Thyroid gland disease
None
Other
Date of treatment completion for heartworm disease
MM slash DD slash YYYY
Diagnosis date of adrenal gland disease
MM slash DD slash YYYY
Diagnosis date of diabetes
MM slash DD slash YYYY
Diagnosis date of thyroid gland disease
MM slash DD slash YYYY
Please type another option here
*
Has your pet ever suffered from an injury requiring emergency care?*
*
Yes
No
If yes, please explain
Please list any previous surgeries your pet has had, along with the date of procedure
Has your pet ever experienced a seizure?
Do you have any behavioral concerns (barking, inappropriate urination, etc.)?
Bone and joint health
Difficulty climbing up or down stairs
Stiffness or limping
Difficulty rising from sitting or resting position
Diagnosed with osteoarthritis, elbow or hip dysplasia, cruciate disease of the knees
Lags behind on walks
General health questions
Bad breath
Allergies (fleas, food, pollen, etc.)
Increased drinking/urination/eating
Unexplained weight change
Vomiting- frequency
Diarrhea or constipation- frequency
Change in activity level or association with family members
New environment or environmental dynamics (new family member, sleeping arrangements, litter, work/play schedule)
Coughing/sneezing/shortness of breath
Panting even while resting
Confusion or disorientation
Change in sleep patterns (sleeps more or less, night vocalizing or pacing)
If allergies, please list
If vomiting - frequency
If diarrhea or constipation - frequency
Do you have pet insurance?
*
Would you like to discuss pet insurance plans?
*
Is there anything specific you would like us to know about your pet today, or have any concerns you would like to discuss?
*
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