Oak Hills Veterinary Clinic & Bird Hospital

1212 Wallace Rd NW
Salem, OR 97304

(503)581-8161

oakhillsvetclinic.com

New Patient and Client Information Sheet

Thank you for your giving Oak Hills Veterinary Clinic and Bird Hospital the opportunity to care for your pet. So that we may become better acquainted, please complete the following:

Patient and Client Information

Owner or Care Provider (required)
First Name (required)
Last Name (required)
Spouse/Partner
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
E-Mail Address :
Primary Phone (required)
Phone TypePhone Number (required)
Additional Phone
Phone TypePhone Number
What is the best time to reach you at home? (required)

Place of Employment

Spouse/Partner's Work Phone Number
Phone TypePhone Number
Spouse/Partner's Place of Employment

If necessary, may we call you at work? (required)
Yes
No


How did you first hear about our hospital? (required)
Yellow Pages
Hospital Sign
Internet
Other
Personal Recommendation
If it was a Personal Recommendation, who may we thank?

So that we are able to suit your individual needs - which do you feel best applies to you?
Please select ONE (required)
I feel the animals in my care are like family members.
I feel the animals in my care are just pets, not family members.


Please select ONE (required)
I want the best medical care available for my pet; please recommend anything that you feel is necessary for good health.
I want good medical care for my pet, but there is a limit to what I am able to have done.
I want you to perform only the services that I request.


Please select ONE (required)
I want to learn as much as I can about pet health care, please explain in detail what has been done for my pet or what is needed.
I would rather not watch my pet's treatments or vaccinations, but want to learn what is needed for optimal care.


PAYMENT IS REQUESTED UPON COMPLETION OF OFFICE VISIT
Please indicate your choice of payment: (required)
Cash
Check
Mastercard/Visa/Discover/AMEX
Care Credit
PET INFORMATION
Pet's Name (required)

Species (required) :
Breed or common name:

Date of birth or Age

Sex: (required)
Male
Female


Medical records at another Veterinary Practice?
Yes
No
I have copies


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


This section is for CATS & DOGS ONLY
Are they Altered? Neutered/Spayed
Neutered
Spayed


Check here if your pet has had vaccines in the last year.
Check here if you brush your pet's teeth.
Date of last dental cleaning

Type of flea prevention used?

Type of heartworm prevention used?

This next section is for BIRDS ONLY
Date of last Gram Stain

Date of last Fecal Analysis

Date of last Complete Blood Count (CBC)

ARE ANY OF THE FOLLOWING A CONCERN TO YOU IN YOUR PET'S BEHAVIOR?
PLEASE CHECK ALL THAT APPLY
Excessive Barking
Biting
Shedding
Straying from home
House training
Wetting/spraying in house
Excessive itching/scratching
Overly rambunctious/overly enthusiastic
Feather destructive behavior
Molting
Screaming
Other
If Other, please describe.

Any prior illnesses or surgeries we should know about?

List your pet's current medications or supplements:

What is your pet's current diet?

What health care or grooming products are you currently using?

List any known drug allergies:

Again, thank you for giving us the opportunity to serve you!
Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Oak Hills Veterinary Clinic & Bird Hospital and Salem Cat Clinic and that charges are due and payable at the time of service.
I have read this statement and -
I Agree
I Disagree



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