New Client Form - Bayshore Animal Hospital

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Owner Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Secondary Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

Authorized Decision-Maker Name(Required)

First Last

Authorized Decision-Maker Phone

If you were referred by someone, who should we thank?

Pet Information

Pet's Name(Required)

Species(Required)

Breed(Required)

Age / Date of Birth(Required)

Sex(Required)

Male

Neutered Male

Female

Spayed Female

Does your pet have a microchip?(Required)

Yes

Microchip ID Number(Required)

Appointment Details

Preferred Appointment Date(Required)

MM slash DD slash YYYY

Preferred Appointment Time(Required)

Hours

Minutes

AM/PM

Primary Reason for Visit(Required)

Please be as detailed as possible

Everything was okay until:(Required)

Describe onset / timeline

Please tell us about your pet's temperament and any special accommodations that may help them feel more comfortable during their visit.(Required)

Our team strives to create a low-stress experience for every pet. Sharing your pet’s preferences, fears, and favorite rewards helps us tailor our approach to their individual needs.

Clinical Assessment

Energy Level(Required)

Normal

Increased

Decreased

Current Medications / Supplements

Name, dose, frequency, last given

Heartworm / Flea & Tick Prevention

Product names

Medication Refills Needed?(Required)

Yes

Which medications?(Required)

Prescription Food Refills Needed?(Required)

Yes

Which prescription food?(Required)

Normal Food (brand/type)

Appetite

Normal

Increased

Decreased

Does your pet eat human foods?

Yes

Water Intake

Normal

Increased

Decreased

Urinary Output Volume

Normal

Increased

Decreased

Urinary Output Frequency

Less

No Change

Symptom Assessment

Coughing?(Required)

Yes

Coughing – how long?(Required)

Vomiting?(Required)

Yes

How long? What does it look like? When did it last occur?(Required)

Changes in Stool Quality?(Required)

Yes

Describe stool changes(Required)

Body Weight

Losing

Gaining

No Change

Unknown

Limping / Lameness?(Required)

Yes

Limping – how long?(Required)

Skin Issues?(Required)

Yes

Skin issues – location on body(Required)

Respiratory Symptoms (check all that apply)(Required)

Coughing

Sneezing

Nasal Discharge

Eye Discharge

None

Travel & Exposure

Recent Travel?(Required)

Yes

Travel – approximate date(Required)

Recent Boarding or Grooming?(Required)

Yes

Where (boarding/grooming facility name)?(Required)

Behavior Concerns

Known Vaccine or Medication Allergies?(Required)

Yes

Please list allergies(Required)

Financial Policy & Authorization

Payment is due in full at time of service. For hospitalized pets, a 50% deposit is required before care begins.

Financial Policy Agreement(Required)

I understand and agree that payment is due in full at time of service. For hospitalized pets, a 50% deposit is required before care begins.

Payment Responsibility(Required)

I accept full financial responsibility for all charges incurred for the care of my pet.

Signature(Required)

Upload Documents (optional)

Drop files here or

Max. file size: 128 MB.