Download & Print FormName* First Last Address* 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 Primary Phone*Secondary Phone*Email* Please check preferred method of contact:* Postcard EmailAdditional contact(s) authorized to make treatment decisions:*Please list First/Last Name(s) and Phone Number(s)How did you hear about Shelburne Veterinary Hospital?* Facebook Friend/Family Google Instagram Other Veterinarian Other Print Ads YelpName of person who referred you so we can thank them*Please let us knowReason for Visit*Previous Vet*Date of Last Visit* MM slash DD slash YYYY Pet InformationPatient Name*Age/Birthday*Species*Breed*Color*Sex*Neutered/Spayed* Yes NoDoes your pet have allergies?* Yes NoPlease list allergies:*Has your pet ever had a reaction to vaccines or medications?* Yes NoPlease describe:*Does your pet have any long term medical problems?* Yes NoPlease describe:*Is your pet on any medications (including over-the-counter and supplements)?* Yes NoPlease describe:*Is there anything else we should know about your pet?*Add another pet?* Yes NoPatient Name*Age/Birthday*Species*Breed*Color*Sex*Neutered/Spayed* Yes NoDoes your pet have allergies?* Yes NoPlease list allergies:*Has your pet ever had a reaction to vaccines or medications?* Yes NoPlease describe:*Does your pet have any long term medical problems?* Yes NoPlease describe:*Is your pet on any medications (including over-the-counter and supplements)?* Yes NoPlease describe:*Is there anything else we should know about your pet?** I HEREBY AUTHORIZE the veterinarian(s) to examine, prescribe for, and/or treat the above described pet(s).* I assume responsibility for all charges incurred in the care and treatment of the above described animal(s). I understand that payment is expected at the time of service, or pick-up.* I also understand that these charges will be paid at the time of service or at the time of releasing my pet(s) to me.* I authorize Shelburne Veterinary Hospital to use my pet(s) image on website and/or social media.Date* MM slash DD slash YYYY SVH is pleased to continue accepting new clients. Due to the high demand for appointments, we require a new client deposit which will be applied to your visit with us. Should you need to reschedule or cancel, we require at least 24 hours' notice. We are able to process deposits by card over the phone.* I acknowledge that if this notice is not provided, my deposit is forfeited.BY SIGNING BELOW, I UNDERSTAND THE FOLLOWING: It is my veterinarian’s recommendation that my pet(s) undergo annual blood work. It is my veterinarian’s recommendation that my pet(s) be tested annually for Anaplasmosis, Lyme, Leptospirosis, and Heartworm disease. 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.*(Sign here)CAPTCHA
