Pet Intake Form "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Your Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Type* Home Cell Email Address* Enter Email Confirm Email Are you the owner of this pet?* Yes No What is your relationship to this pet?*Your Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Email Address* Enter Email Confirm Email Has this pet been here before?* Yes No I'm not sure Secondary Contact* First Last Phone*Type* Home Cell Reason for today's visit*Patient (Pet) InformationPet's Name*Upload a picture of your pet. This is optional.Max. file size: 512 MB. Species* Dog Cat Gender* Male Female Unsure Breeding Status* Spayed Fully Functional Unsure Breeding Status* Neutered Fully Functional Unsure Breed*Mixed BreedAffenpinscherAfghan HoundAiredale TerrierAkitaAlaskan MalamuteAmerican BulldogAmerican EskimoAmerican FoxhoundAustralian Cattle DogAustralian ShepherdAustralian TerrierBasenjiBasset HoundBeagleBearded CollieBernese Mountain DogBichon FriseBlack Russian TerrierBloodhoundBorder CollieBorder TerrierBorzoiBoston TerrierBouvier des FlandresBoxerBriardBrittanyBrussels GriffonBull TerrierBullmastiffCairn TerrierCanaan DogCane CorsoCardigan Welsh CorgiCavalier King Charles SpanielChesapeake Bay RetrieverChihuahuaChinese CrestedChinese Shar-PeiChow ChowClumber SpanielCocker SpanielCollieCorgiCurly-Coated RetrieverDachshundDalmatianDandie Dinmont TerrierDoberman PinscherEnglish BulldogEnglish Cocker SpanielEnglish FoxhoundEnglish SetterEnglish Springer SpanielEnglish Toy SpanielEntlebucher Mountain DogField SpanielFinnish LapphundFinnish SpitzFlat-Coated RetrieverFrench BulldogGerman PinscherGerman ShepherdGerman Shorthaired PointerGerman Wirehaired PointerGiant SchnauzerGolden RetrieverGordon SetterGreat DaneGreat PyreneesGreater Swiss Mountain DogGreyhoundHarrierHavaneseIbizan HoundIcelandic SheepdogIrish Red and White SetterIrish SetterIrish TerrierIrish Water SpanielIrish WolfhoundItalian GreyhoundJapanese ChinJapanese SpitzKeeshondKerry Blue TerrierKomondorKuvaszLabrador RetrieverLakeland TerrierLeonbergerLhasa ApsoLowchenMalteseManchester TerrierMastiffMiniature PinscherMiniature SchnauzerNeapolitan MastiffNewfoundlandNorfolk TerrierNorwegian BuhundNorwegian ElkhoundNorwegian LundehundOld English SheepdogOtterhoundPapillonPekingesePembroke Welsh CorgiPetit Basset Griffon VendeenPharaoh HoundPointerPomeranianPoodle (Miniature)Poodle (Standard)Poodle (Toy)Portuguese PodengoPortuguese Water DogPudelpointerPugPyrenean Mountain DogRat TerrierRedbone CoonhoundRhodesian RidgebackRottweilerSaint BernardSalukiSamoyedSchipperkeScottish DeerhoundScottish TerrierShetland SheepdogShiba InuShih TzuSiberian HuskySilky TerrierSkye TerrierSloughiSmooth Fox TerrierSoft-Coated Wheaten TerrierSpanish Water DogSpinone ItalianoStaffordshire Bull TerrierStandard PoodleStandard SchnauzerSussex SpanielSwedish VallhundThai RidgebackTibetan MastiffToy Fox TerrierTreeing Walker CoonhoundWelsh Springer SpanielWelsh TerrierWest Highland White TerrierWhippetWire Fox TerrierWirehaired DachshundWirehaired Pointing GriffonXoloitzcuintliYorkshire TerrierOtherPlease describe*Please describe.*Breed*AbyssinianAmerican ShorthairBengalBirmanCalicoDevon RexDomestic LonghairDomestic ShorthairHimalayanMaine CoonOriental ShorthairSiamesePersianRagdollSphynxOtherPlease describe*Do you know your pet's birthday?* No Yes Pet's Birthday* MM slash DD slash YYYY Age*YearsMonths Add RemoveColor(s)*BlackBrown/Chocolate/LiverYellow/Gold/Tan/FawnRed-Coppery or reddish shadesWhiteBlue/Grey/SilverBrindleMerleBicolor/TricolorOtherPlease describe.*Color(s)*BlackBlue/GreyRed/Orange/GingerWhiteCreamBrown/ChocolateCinnamon/FawnTabby PatternsTortoiseshellOtherPlease describe.*Special MarkingsWho is your regular veterinarian?*Select a Vet5 Mile Vet9-Tel Animal HospitalA W Animal HospitalA-Care Animal ClinicA-Quality Care Veterinary HospitalAce Animal ClinicAdvanced Animal EmergencyAdvanced Pet Care of OaklandAdvanced Veterinary Care Group CantonAdvanced Veterinary Medical GroupAEC NoviAEC RochesterAffiliated Veterinary Emergency ServiceAffordable Veterinary Care CenterAirport Veterinary Hosp.Alexis Road Animal HospitalAlfa Animal Care-Farmington HillsAlfa Animal Care-Sterling HeightsAll About AnimalsAll Creatures Veterinary ServicesAllen Animal HospitalAlmont-Dryden Veterinary HospitalAlpine Animal HospitalAlpine Veterinary ClinicAlsager Animal Care CenterAnchor Bay Veterinary HospitalAngel Animal HospitalAnimal Advocates Veterinary HospitalAnimal Cancer & Imaging CenterAnimal Care Clinic-InksterAnimal Care Hospital of LivoniaAnimal Clinic EastAnimal Clinic of Sterling HeightsAnimal Friends Vet CareAnimal Health AssociatesAnimal Health Care of North BranchAnimal Health ClinicAnimal Hospital Maple OrchardAnimal Hospital Of ChesterfieldAnimal Hospital of KentwoodAnimal Hospital of LakeportAnimal Kingdom Veterinary HospitalAnimal Medical Center of LapeerAnimal Medical Center of SalineAnimal Medical Center of TroyAnimal Medical Center of Van BurenAnimal Surgical Center of MichiganAnimal Welfare SocietyAnn Arbor Animal HospitalAPAWS Veterinary HospitalArbor Hills Animal ClinicArbor Pointe Veterinary Hosp.Arbor View Veterinary HospitalArk Animal ClinicArk Veterinary HospitalAsh Veterinary ClinicAuburn Animal HospitalAvon Animal ClinicB.C. Home Vet CareBad Axe Animal Medical ClinicBanfield Pet Hospital - Chesterfield TownshipBanfield Pet Hospital - LivoniaBanfield Pet Hospital - NorthvilleBanfield Pet Hospital - Rochester HillsBanfield Pet Hospital - RosevilleBanfield Pet Hospital - SouthfieldBanfield Pet Hospital - TroyBanfield Pet Hospital - UticaBanfield Pet Hospital - WaterfordBanfield Pet Hospital - WoodhavenBay Valley Animal HospitalBaylis Animal HospitalBell Veterinary Clinic-MetamoraBell Veterinary Clinic-OxfordBergmans Veterinary ClinicBerkley Animal HospitalBeverly Hills Veterinary AssociatesBlack River Veterinary ClinicBloom Animal HospitalBloomfield Animal HospitalBloomfield Pointe Animal HospitalBlue Cross Animal HospitalBlue Paws Animal HospitalBlue Pearl Auburn HillsBlue Pearl Neurology FarmingtonBluePearl Ann ArborBluePearl Grand RapidsBluepearl SouthfieldBranton Animal ClinicBreckenridge VeterinaryBriarpoint Veterinary ClinicBriarwood Veterinary HospitalBrinker Veterinary HospitalBrooks Animal ClinicBrown County Veterinary ServiceBurrwood VeterinaryBurtchville Veterinary ClinicCahill Veterinary HospitalCambridge Animal ClinicCameron Medical CenterCanton Animal HospitalCanton Center Animal Hosp.Care Veterinary ServicesCaro Veterinary ClinicCarousel Cat ClinicCaseville Small Animal CliniccatCat Care of Rochester HillsCats VeterinaryCedar Animal HospitalCedar Creek Veterinary ClnicCenterline Veterinary HospitalCherry Bend Animal Hospital VCACherry Hill Animal ClinicChilds Veterinary ClinicClarkston Animal Medical CenterClarkston Veterinary ClinicClio Animal HospitalCommerce Animal HospitalCommerce Village Veterinary HospitalCompanion Animal Care ClinicCompanion Animal Hospital - LindenCompassionate Care Animal HospitalCottonwood Veterinary ClinicCreekside Animal HospitalCroswell Veterinary ServiceD'Adamo Veterinary HospitalDaley Road Animal CareDandy Acres Animal HospitalDearborn Family Pet CareDeporre Veterinary Hosp.Dine Veterinary HospitalDix Animal HospitalDoc McStuffin Pet ClinicDogwood Veterinary Referral Center - Blue PearlDonaldson Animal HospitalDowntown Birmingham VeterinaryDr. Fitz's Bayside Animal ClinicDr. John Herman Mobile VetDunckel Veterinary ClinicDworkis Dog and Cat HospitalEast Detroit Animal HospitalEast Lansing Veterinary ClinicEastpointe Animal HospitalEastside Veterinary HospitalElk Rapids Animal HospitalEmergency Veterinary Hospital-Ann ArborExclusively Cats Veterinary HospitalFaithful Friends Veterinary CareFamily Paws VeterinaryFamily Pet Practice of WaterfordFamily Pet Practice WixomFamily Pet Practice-WixomFenton Veterinary ClinicFord Caputo Animal HospitalForest Glade Animal HospitalFowlerville Veterinary ClinicFox Run Animal HospitalFrancis Animal HospitalGarden City Veterinary HospitalGasow Veterinary HospitalGibraltar Veterinary HospitalGladwin Veterinary HospitalGoodison Veterinary Center, P.C.Grand Blanc Veterinary HospitalGrand River Veterinary Hosp.Great Lakes Animal HospitalGreenfield Veterinary HospitalGreenwood Veterinary Associates PCGriffith Veterinary Hospital WestlandGriffith Veterinary Hospital Whitmore LakeGroesbeck Animal HospitalGrosse Pointe Animal ClinicGull Lake Animal HospitalHamilton Animal HospitalHarper Woods Veterinary HospitalHartrick Veterinary ClinicHarvey Animal HospitalHaslett Animal HospitalHealing Care Animal HospitalHealthy Paws Veterinary Medical CenterHeritage Vet HospitalHidden Springs Veterinary ClinicHighland Veterinary HospitalHilldale Veterinary HospitalHilton Veterinary ClinicHollow Corners Veterinary ServicesHome-VetHometown Veterinary HospitalHoover Road Animal HospitalHurley Dog and Cat HospitalHuron Veterinary ClinicImlay City Veterinary ClinicIn the Pink Veterinary Clinic/CobblestoneIndian River Veterinary ClinicIrons Animal HospitalIthica Animal HospitalJefferson Veterinary ClinicJeffrey Animal HospitalKelly Veterinary ClinicKimball Animal HospitalKitty's DoctorKoprowski Veterinary ClinicKrause Veterinary ClinicLaFond Veterinary Hosp.Lake Huron Veterinary ClinicLake Orion Veterinary HospitalLakeside Animal HospitalLakeville Animal ClinicLaursen Veterinary ServiceLeader Dogs for the BlindLegacy Pet CareLevan Road Veterinary HospitalLilley Veterinary Medical CenterLincoln Park VeterinaryLisner Animal HospitalLittle Friends of FerndaleLivingston Veterinary ClinicLivonia Veterinary HospitalLong Lake Animal HospitalLuv-N-Care Animal HospitalMacomb Center Veterinary Hosp.Macomb Humane SocietyMacomb Veterinary AssociatesMACS Veterinary Clinic (Michigan Anti-Cruelty Society)Madison Veterinary HospitalMaple Grove Veterinary ClinicMaple Veterinary HospitalMarysville Veterinary ClinicMeadowbrook Animal ClinicMeadowbrook Veterinary ClinicMedVetMetropolitan Veterinary CenterMichigan Animal Hospital LivernoisMichigan Avenue Animal HospitalMichigan Humane - Detroit - Grosfeld Veterinary CenterMichigan Humane - Livingston - Center for Animal CareMichigan Humane - Rochester Hills - Center for Animal CareMichigan Humane - Westland - Berman Center for Animal CareMichigan State University Veterinary Medical CenterMidMichigan Veterinary HospitalMidtown Animal HospitalMilford Veterinary Clinic PCMilwood Animal ClinicMiVet Animal ClinicMonroe Veterinary ClinicMoore Veterinary HospitalMorris Hospital for Veterinary ServicesMorrison Animal HospitalMSU Veterinary CenterMt Pleasant Animal Hospital, P.CMt. Pleasant Animal HospitalNatural Healing Pet CareNichols Veterinary ClinicNorth Main Animal HospitalNorth River Animal HospitalNorth Suburban Veterinary HospNorthland Veterinary ClinicNorthville Animal HospitalNorthwest Veterinary Clinic, PCNot KnownNovi Veterinary ClinicNucci Veterinary HospitalOakland Animal HospitalOakland Hills VeterinaryOakland Veterinary Referral ServicesOakwood Veterinary HospitalOrchard Lake Animal HospitalOrchard Maple Vet ClinicOrion Animal Care CenterOrion Animal HospitalOrion Oaks Animal HospitalOrtonville Animal ClinicOvid-Elsie Animal ClinicOxford Animal ClinicPaint Creek Animal ClinicParker Veterinary HospitalParkview Animal HospitalParkway Veterinary Clinic - PlymouthParkway Veterinary HospitalPatterson Dog & Cat Hospital (Detroit)Patterson Veterinary HospitalPawsitive Care Vet ClinicPawsitive Steps RehabPet Authority Animal HospitalPet Care ClinicPet DoctorPet Urgent Care TroyPetCare PlusPets Ahoy Animal HospitalPetSmart Veterinary ServicesPetWellClinic Royal OakPierson Pet HospitalPlatz Animal HospitalPlaza Veterinary HospitalPlymouth Beech Animal HospitalPlymouth Veterinary Hosp.Pointe Animal HospitalPoppy Hill VetPytel Veterinary ClinicRed Barn Veterinary Medical CenterReliance Animal HospitalRemrock FarmsRichmond Veterinary ClinicRiverfront Animal HospitalRiverside Animal HospitalRiverside Cat HospitalRiverview Veterinary CenterRoadside Veterinary ClinicRochester Veterinary HospitalRomeo Veterinary HospitalRoose Animal HospitalRosedale Veterinary Housecalls: Begnigna Andrew A DVMRoss Hospital for AnimalsRossoni Animal HospitalRoyal Oak Animal HospitalSalem Veterinary ServicesSchultz Veterinary ClinicSerenity Animal HospitalSharp Animal HospitalSheehy Animal HospitalShelby Veterinary HospitalSheldon Veterinary HospitalSheppard Alternative Animal CareSnider Veterinary Services PCSnyder Veterinary ClinicSomerset Veterinary HospitalSouth Arbor Animal HospitalSouth Lyon Animal ClinicSouth Shore Animal HospitalSouthfield Veterinary HospitalSouthgate Animal HospitalSouthpoint Veterinary Hosp.Spartan Veterinary ClinicSpringfield Veterinary ClinicSt. Clair Bed & BoneSt. Francis Animal HospitalSt. Julian's Cat CareStadium Veterinary ServicesStony Creek Veterinary HospitalStrong Village Veterinary CenterStrong Village Veterinary HospitalSurrey Veterinary ClinicTail WaggersTaylor Veterinary ClinicTecumseh Animal HospitalThe Kitty ClinicThomson Animal ClinicThorpe Animal HospitalTowne & Country Animal HospitalTroy & Heights Animal HospitalTroy Veterinary HospitalTruHeal Veterinary HospitalUnion Lake Veterinary ClinicUnleashed Pet CareVCA Allen Park Animal HospitalVCA Animal Hospital of Garden CityVCA Beech Road Animal HospitalVCA Clinton Township Animal HospitalVCA Countryside Animal Hospital of HamburgVCA Countryside Animal Hospital of HowellVCA Farmington Hills Animal HospitalVCA Southland Animal HospitalVCA St. Clair Shores Animal HospitalVCA Swartz Creek Animal HospitalVCA White Lake Animal HospitalVCA Woodland Animal HospitalVES WestVet IQ Petcare in Meijer - WarrenVetco Total CareVeterinary Associates, LLCVeterinary Cardiology Consultants - NoviVeterinary Cardiology Consultants - RochesterVeterinary Care Center of RichmondVeterinary Care Services of MilfordVeterinary Emergency ServiceVeterinary GeneralVeterinary Health CenterVeterinary House CallsVeterinary Vision of RochesterVetIQ Petcare Royal OakVets2UVetSelect Animal Hospital of CommerceVetSelect Animal Hospital of DearbornVetSelect Animal Hospital of NoviVillage Animal HealthcareWadhams Road Animal Care CenterWalled Lake Veterinary HospitalWarren Animal ClinicWarren Woods Veterinary HospitalWaterford Animal ClinicWest Arbor Veterinary HospitalWest Bloomfield Veterinary HospitalWest Branch Veterinary ServicesWest Flint Animal HospitalWest Warren VeterinaryWest Woodward Animal ClinicWestland Veterinary HospitalWestside Veterinary HospitalWestwood Hills Animal HospitalWilson Veterinary HospitalWoodhaven Animal HospitalWoodland Animal HospitalWoodward Veterinary Home CareWyandotte Animal HospitalYale Veterinary HospitalOtherVet MatchThis field is hidden when viewing the formVet Match DetailsThis field is hidden when viewing the formStreet AddressThis field is hidden when viewing the formCityThis field is hidden when viewing the formStateThis field is hidden when viewing the formZipThis field is hidden when viewing the formEmailThis field is hidden when viewing the formPhoneThis field is hidden when viewing the formWebsiteThis field is hidden when viewing the formCountryPlease provide us your vet's contact information.Vet Business Name*Vet Business Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email Website I authorize the release of my pet's complete medical records to any requesting veterinary clinic.* Yes No This field is hidden when viewing the formDO NOT RELEASE ANY MEDICAL RECORDS to ANY REQUESTING VETERINARY CLINICDoes your pet have any history of aggression* Yes No Please check all that apply.* Animal aggression Human aggression Needs muzzle - will bite Sensitive body parts Nervousness Has there been any prior incident(s) at a veterinary clinic that required sedation? Other Please note sensitive body parts.*Please describe*Do you have pet insurance?* Yes No Please tell us who your provider is.* Pet Assure Lemonade Fetch Trupanion Nationwide Spot Pet's Best Metlife Pumpkin AKC Pet Insurance Banfield Optimum Wellness Other Who is your provider?*How did you hear about our clinic?*Drove ByGoogleOnline PresenceSocial MediaFriend or Family MemberPhysical EventVeterinarianOtherPlease describe*Terms of ServiceThe emergency exam fee is $90.00. All diagnostics, medications, and treatments are additional to the exam fee. An estimate for additional services and medications will be provided and you will have the opportunity to approve or decline and recommendations. Payment is due in full at the time of services rendered. We do not offer any form of billing. We accept all major credit cards, Cherry payment plan, Care Credit, ApplePay and cash.* I agree. Information and/or photos may be used for teaching, continuing education, website, veterinary literature, promotional materials, and the like. I authorize the release of case/patient information for such purposes; pet owner confidentiality will be maintained. I agree. Signature*No Refund Policy NoticeI understand that all veterinary services rendered, including exams, diagnostics, treatments, and procedures, are non-refundable once performed. I also acknowledge that all medications dispensed or administered are non-refundable. By signing below, I accept full financial responsibility for all approved services and products.* I agree. Signature*Date* MM slash DD slash YYYY
