Enrollment and Terms Agreement for Veterinarians OWNER INFORMATIONOwner's Name: *FirstMiddleLastCo-owner/Spouse's Name:FirstMiddleLastHome Phone:Work Phone:Cell Phone:Other Phone (Co-Owner/Spouse Work or Cell):WorkCellOtherBest Phone Number: *Best Time to Call:Email Address: *Fax Number:Mailing Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCheck if Street Address is same as Mailing AddressCheck box if Same as AboveStreet Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeName of Employer:Occupation:PATIENT INFORMATIONPet's Call Name: *Age/DOB:Breed:Species:CanineFelineOtherSpecies (if Other):Color:Sex:Male, IntactMale, NeuteredFemale, IntactFemale, SpayedREFERRING VETERINARIANName:FirstLastHospital Name:City:State:Phone:PATIENT HISTORYCURRENT MEDICAL HISTORYPlease describe your pet's current problem (symptoms) in your own words: *Flea and tick preventative: *YesNoName of flea and tick preventative: *Frequency: *Heartworm preventative: *YesNoName of heartworm preventative: *Frequency: *Supplements/herbal remedies: *Frequency: *Any other medications? *YesNoIf yes, describe:Date/Age problem first noticed: *Has your pet's condition improved with any of the therapy that has been tried before? *NoYesIf yes, explain: *Is the problem: *Sudden GradualContinualIntermittentWhat area of the body did the problem begin? *Does your pet have exposure or live within 1 mile of the following?CatsDogsHorsesCattleTobacco SmokePerfumes/CandlesPotpurriPet Bird/ FeathersSheep/ WoolPine scented cleanersSpreading Day FlowerWandering Jew PlantDove WeedWhen was the last time you found a flea or tick on your pet? *What is being used to eradicate fleas and how often? *In the homeWhat is being used to eradicate fleas and how often? *In the yardDoes your pet have issues:eatingdrinkingvomitingurinatingdefecatinglethargyweight-lossDescribe: Are there any other facts you feel might be helpful? PAST MEDICAL HISTORYPlease check all that apply and describe:SeizureBlood TransfusionExposure to Toxic SubstancesAllergies to drugsOtherDescribe:Previous medical problems/surgeries:Is your pet aggressive to people or other pets? *NoYesIf yes, describe:Is your pet up to date on vaccines? *NoYesIf no, explain:Lives Indoors *%Lives Outdoors *%Do you live in an: *ApartmentHomeDo you live in the: *CitySuburbsRuralDescribe your pet's diet, be sure to include brand, type, dry, moist, duration fed, treats, any charges, etc: *When & where has your pet ever traveled outside Florida:At what age was your pet when you acquired him/her? *PLEASE FILL IN THE BOXES BELOW:Is the problem seasonal? *YesNoExplain:Is your pet itchy? (Itchy = scratching, biting, chewing, licking) *YesNoExplain: Is there hair loss? *YesNoExplain:Are there changes in color of the hair? *YesNoExplain:Are there changes in the color of the skin? *YesNoExplain:Do you have other pets in the household? *YesNoDescribe them (if any) (for example: dog/cat inside/outside):Does other pets have any skin problems? *YesNoDescribe (if any): Do any members of the household have any skin problems? *YesNoDescribe (if any): Do you have a fenced in yard? *YesNoExplain: Are carpet deodorizers used in the home? *YesNoWhat kind?: Are you able to administer medication to your pet? (tablets, capsules, liquid) *YesNoDescribe any issues: Are you able to bathe your pet? *YesNoIf so, how often and for how long (minutes)?: Does your pet visit people in health care/assisted living facilities? *YesNoExplain: Do you, or anyone in your household feed feral or stray cats, dogs, or wildlife around your home? *YesNoExplain: Do you have birdfeeders in / around your yard? *YesNoExplain: Method(s) of Payment:CashCheckVisaMastercardDiscoverAmerican ExpressCare CreditI am financially responsible for all professional fees related to the above-mentioned pet by the Institute of Veterinary Specialists. I understand that payment is due at the time of service. By signing this form, I attest that I have read and will comply with these terms.EmailSubmit
