Download & Print FormToday’s Date(Required) MM slash DD slash YYYY Primary OwnerName(Required) First Last Mailing Address(Required) Street Address Address Line 2 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 Additional contact(s) authorized to make treatment decisions:(Required)Please list in order of preference: First/Last Name(s) and Phone Number(s)Primary Phone(Required)Secondary Phone(Required)Email(Required) Please check preferred method of contact:(Required) Email Phone TextHow did you hear about Shelburne Veterinary Hospital?(Required) Facebook Friend/Family Google Instagram Other Veterinary Practice Print Ads Yelp OtherName of person who referred you so we can thank them(Required)Please let us knowOther Veterinary PracticeReason for Visit(Required)Previous Vet(Required)Date of Last Visit(Required) MM slash DD slash YYYY Pet InformationPatient Name(Required)Age/Birthday(Required)Species(Required)Breed(Required)Color(Required)Sex(Required)Neutered/Spayed(Required) Yes NoDoes your pet have allergies?(Required) Yes NoPlease list allergies:(Required)Has your pet ever had a reaction to vaccines or medications?(Required) Yes NoPlease describe:(Required)Does your pet have any long term medical problems?(Required) Yes NoPlease describe:(Required)Is your pet on any medications (including over-the-counter and supplements)?(Required) Yes NoPlease describe:(Required)Is there anything else we should know about your pet?(Required)Add another pet?(Required) Yes NoPatient Name(Required)Age/Birthday(Required)Species(Required)Breed(Required)Color(Required)Sex(Required)Neutered/Spayed(Required) Yes NoDoes your pet have allergies?(Required) Yes NoPlease list allergies:(Required)Has your pet ever had a reaction to vaccines or medications?(Required) Yes NoPlease describe:(Required)Does your pet have any long term medical problems?(Required) Yes NoPlease describe:(Required)Is your pet on any medications (including over-the-counter and supplements)?(Required) Yes NoPlease describe:(Required)Is there anything else we should know about your pet?(Required)AS “PRIMARY OWNER” AND BY SIGNING BELOW, I UNDERSTAND THE FOLLOWING(Required) It is my veterinarian’s recommendation that my pet(s) undergo annual blood work.(Required) It is my veterinarian’s recommendation that my pet(s) be tested annually for Anaplasmosis, Lyme, Leptospirosis, and Heartworm disease.(Required) When medications are used on a chronic basis for the treatment of my pet(s) that it is necessary to routinely monitor blood samples to make certain that the medications are not causing deleterious effects to my pet(s) health. These drugs include but are not limited to: NSAIDs, Glucocorticoids (steroids) and/or Opioids.(Required) I HEREBY AUTHORIZE the veterinarian(s) to examine, prescribe for, and/or treat the above described pet(s).(Required) I ASSUME RESPONSIBILITY for all charges incurred in the care and treatment of the above described animal(s).(Required) I UNDERSTAND that these charges will be paid at the time of service or at the time of releasing my pet(s) to me and I ACKNOWLEDGE that balances older than 30 days from the date of service will be subject to a 1.5% finance charge per month until paid.(Required) I UNDERSTAND that at least 24 hours’ notice is required to cancel or reschedule an appointment for my pet and if this notice is not provided a cancellation fee will be applied to my account.(Required) I AUTHORIZE Shelburne Veterinary Hospital to use my pet(s) image on their website and/or social media sites.Date(Required) MM slash DD slash YYYY Owner/Agent Signature(Required)(Sign here)CAPTCHA
