Client Intake Form

Thank you for choosing Austintown Veterinary Clinic to care for your pet. Filling out this form before your appointment will greatly assist us in adding you and your pet to our system. We will be happy to contact your previous veterinarian to obtain any necessary information or documentation regarding your pet's medical history.

Pet Information

Pet Name*

Pet 1:
Pet 2:
Pet 3:

Species*

Pet 1:
Pet 2:
Pet 3:

Color/Markings*

Pet 1:
Pet 2:
Pet 3:

List Gender (Intact Male / Intact Female / Neutered Male / Spayed Female)*

Pet 1:
Pet 2:
Pet 3:

Age or Birthday*

Pet 1:
Pet 2:
Pet 3:

Do your pet(s) have any allergies? If yes, please list and specify which pet:

What medications are your pet(s) taking?
Please include: Drug Name & Strength / Dose / Frequency / Last Given / Refill Needed?

Does your pet(s) have insurance?*

Yes

We are happy to call your previous veterinarian to obtain a copy of your pet’s records.
Please provide us with the following information: Practice Name / City / State / Phone / Email

Owner Information

How did you hear about us?*

Drive by / Sign

Internet

Personal Referral

Other

Personal Referral: Is there a client, business or organization we can thank for your referral?

Please type your initials in agreement in each box below:*

I am the owner or agent for the animal described above, and I have the authority to execute this consent.
I understand that payment is due in full at the time services are rendered.
I understand that if I do not show up for a scheduled appointment, I will be required to pay a deposit before scheduling another appointment.
I agree that I and any authorized agent that represents me will always treat all staff members and other clients with respect. I understand that Austintown Veterinary Clinic has zero tolerance for swearing, yelling, or disrespectful speech toward any staff member or other client. Behavior as such can result in termination of care. All staff members are empowered to report all abuse from clients.?
I agree to always keep my pet on a leash or in a carrier while in the lobby for patient and human safety.
I agree to inform the staff if my pet has ever been aggressive, bitten anyone, or required a muzzle or extra restraint in any past circumstances, veterinary-related or otherwise.
I authorize Austintown Veterinary Clinic to share my pet’s medical records with facilities when requested by a third party, such as a veterinary clinic, groomer, boarding facility, training, day care, insurance, etc., or with law enforcement, animal control, etc.