Pet Intake Form "*" indicates required fields EmailThis 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* Enter Email Confirm Email Are you the owner of this pet?* Yes No What is your relationship to this pet?*Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Email* 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*Species* Dog Cat Gender* Male Female Breeding Status* Spayed Fully Functional Breeding Status* Neutered Fully Functional 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*AgeYearsMonths Add RemoveYour pet's birthdate MM slash DD slash YYYY Color(s)*BlackBrown/Chocolate/LiverYellow/Gold/Tan/FawnRed-Coppery or reddish shadesWhiteBlue/Grey/SilverBrindleMerleBicolor/TricolorOtherColor(s)*BlackBlue/GreyRed/Orange/GingerWhiteCreamBrown/ChocolateCinnamon/FawnTabby PatternsTortoiseshellOtherSpecial MarkingsRegular Veterinarian (Hospital Name/Location)*A Care Animal Clinic | 1701 Rochester Rd., Troy | 248-524-0500Animal Clinic of Sterling Heights | 39990 Van Dyke Ave. | 586-939-4020Animal Wellness Clinic of Troy | 1701 Rochester Rd. | 248-524-0500Animal Clinic of Sterling Heights | 39990 Van Dyke Ave. | 586-939-4020This field is hidden when viewing the formstaff@animalwellnessclinicoftroy.com*I authorize the release of my pet's complete medical records to any requesting veterinary clinic.* Yes No Does 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 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 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*Date* MM slash DD slash YYYY
