New Client Form for Mount Pleasant Animal Hospital SC

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New Client FormCourtney DeWinter2025-01-28T05:56:19+00:00

New Client Form

"*" indicates required fields

Owner Information

Name*

First Name Last Name

Primary Mobile Number*

Please enter your email*

example@example.com

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Secondary owner information

First Name Last Name

Phone

Please enter a valid phone number.

Emergency

First Name Last Name

Phone

Please enter a valid phone number.

Preferred contact mode*

Call

Text

How did you hear about us?*

Social Media

Google Search

Drove By

Personal Referral

Rescue/AKC

In the future, I may request that my pet’s consolidated medical information or entire medical chart be transferred elsewhere (kennel, groomer, daycare, another veterinarian, other). I understand that the medical chart is a legal document that may also contain sensitive information about me and by requesting the transfer of my pet’s medical record, I am authorizing the release of its contents. I hereby authorized the veterinarian to examine, prescribe for, and/or treat the animal(s) described on the following pages. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.

Animal hospitals

Animal hospitals of the lowcountry would like your permission to use images taken of your pet on our website and social media platforms. If you do not consent to have your pet’s picture used, please click this box.

Signature of responsible party*

Sign Here

Date*

DD dash MM dash YYYY

Pet Health History Pet Information

Name*

Breed*

Birthdate*

DD dash MM dash YYYY

Color*

Sex*

Previous Veterinarian

Previous Veterinarian*

Purpose of last visit*

Date of last visit*

DD dash MM dash YYYY

Date of last vaccines*

DD dash MM dash YYYY

Has your pet ever been sick after receiving vaccinations?*

Is your pet on heartworm prevention?*

Yes

Product Name

Date of last dose given

DD dash MM dash YYYY

Is your pet on flea and tick prevention?*

Yes

Product Name

Date of last dose given

DD dash MM dash YYYY

Is your pet currently taking any long term medications?*

Yes

If yes, please list

What foods are you currently feeding your pet? please list all sources, brands, and treats*

Does your pet have a history of ear infections, skin infections, or hairloss?*

Has your pet ever experienced a serious illness or disease?*

Has your pet ever been diagnosed with any of the following conditions?*

Adrenal gland disease

Diabetes

Heartworm disease

Thyroid gland disease

None

Other

Date of treatment completion for heartworm disease

DD dash MM dash YYYY

Diagnosis date of adrenal gland disease

DD dash MM dash YYYY

Diagnosis date of diabetes

DD dash MM dash YYYY

Diagnosis date of thyroid gland disease

DD dash MM dash YYYY

Please type another option here*

Has your pet ever suffered from an injury requiring emergency care?**

Yes

If yes, please explain

Please list any previous surgeries your pet has had, along with the date of procedure

Has your pet ever experienced a seizure?

Do you have any behavioral concerns (barking, inappropriate urination, etc.)?

Bone and joint health

Difficulty climbing up or down stairs

Stiffness or limping

Difficulty rising from sitting or resting position

Diagnosed with osteoarthritis, elbow or hip dysplasia, cruciate disease of the knees

Lags behind on walks

General health questions

Bad breath

Allergies (fleas, food, pollen, etc.)

Increased drinking/urination/eating

Unexplained weight change

Vomiting- frequency

Diarrhea or constipation- frequency

Change in activity level or association with family members

New environment or environmental dynamics (new family member, sleeping arrangements, litter, work/play schedule)

Coughing/sneezing/shortness of breath

Panting even while resting

Confusion or disorientation

Change in sleep patterns (sleeps more or less, night vocalizing or pacing)

If allergies, please list

If vomiting - frequency

If diarrhea or constipation - frequency

Do you have pet insurance?*

Would you like to discuss pet insurance plans?*

Is there anything specific you would like us to know about your pet today, or have any concerns you would like to discuss?*

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1217 Ben Sawyer Blvd
Mount Pleasant, SC 29464
Phone: (843) 884-4921
Email: Email Us

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