New Client Form | Lake Huron Veterinary Clinic in Port Huron, MI

Please have the following New Client Form filled out prior to your pet’s visit to the hospital

New Client

Patient Information

Patient's First Name(Required)

Patient's Last Name(Required)

Email(Required)

Driver's License(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Phone Number(Required)

Patient Information

Pet's Name(Required)

Species(Required)

Breed(Required)

Sex(Required)

Spayed/Neutered(Required)

Yes

Birthdate(Required)

Appointment Date(Required)

Appointment Time(Required)

AM/PM

Is your appointment scheduled with a veterinarian or technician?(Required)

Veterinarian

Technician

Not Sure

Are you a new client?(Required)

Yes

What diet are you currently feeding your pet? Please include frequency and how much.(Required)

Is your pet on flea/tick/heartworm prevention?(Required)

Yes

Has your pet been coughing?(Required)

Yes

Has your pet been sneezing?(Required)

Yes

Does your pet have nasal discharge?(Required)

Yes

If so, what color and which nostril(s)?

Has your pet had diarrhea?(Required)

Yes

Has your pet been vomiting?(Required)

Yes

If your pet has been vomiting, when what the last time and describe the vomit.

Has your pet had diarrhea?(Required)

Yes

Does your pet's stool look normal color?(Required)

Yes

If no, is it black or bloody? Describe.

Has your pet been drinking more?(Required)

Yes

Has your pet been urinating more?(Required)

Yes

Has your pet's appetite changed?(Required)

Yes

Have you seen your pet's urine?(Required)

Yes

If so, what's the color and the amount?

Has your pet's appetite changed?(Required)

Yes

If so, describe how.

When was the last time you saw a bowel movement and what did it look like?(Required)

Any change in diet?(Required)

Yes

If yes, when and what did you change in their diet?

Is your pet lethargic?(Required)

Yes

If yes, how long have they been lethargic?

Is your pet here because it is limping?(Required)

Yes

If yes, how long has your pet been limping, and which leg for how long?

Please list all medications your pet is on and when they were last given.(Required)

Has your pet cried out?(Required)

Yes

If yes, what was your pet doing when this occurred?

Does your pet have problems with one or both of their eyes?(Required)

Yes

If yes, which eye? Describe any drainage or symptoms.

Does your pet have problems with one or both of its ears?(Required)

Yes

If yes, which ear? Describe any discharge or symptoms.

Do you have concerns with your pet’s teeth?(Required)

Yes

If yes, please describe.

Would you like your pet’s nails trimmed while here?(Required)

Yes

If there are if any concerns with the nails, please describe.

Would you like your pet’s anal glands emptied?(Required)

Yes

If there are any concerns with them, any scooting or licking, please describe.

Are there any new lumps or bumps you have found?(Required)

Yes

If yes, where are they and how long have they been present?

Please use this comment section to include any questions or concerns you have. Please also include any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.(Required)

Curbside appointments must arrive 10 minutes prior to the appointment. If you are scheduled for a routine, annual exam, we recommend yearly blood work and viral screening, fecals checked twice yearly, and vaccines due updated. We will provide an estimate of what we have in our records that are needed for your pet for your review when we come to your car.

Please have your pet on the leash or in a carrier before we come to the car.

For the safety of cats, we ask you to please bring your cat to their appointment in a carrier (not on a leash).

When you park, please call the office to let us know once you have arrived. To help us assist, please let us know the color, make, and model of your car.(Required)

(White Jeep Wrangler)

I authorize curbside service and care of my pet by the veterinarians and staff of Lake Huron Veterinary Clinic. I understand this may involve my pet being accompanied by a staff member during their visit,rather than myself. I understand that staff members will be handling my pet;they may be approaching and/or partially entering my vehicle or meeting me at the clinic door. Further medical authorization of recommended treatment(s) will be done via phone communication; I consent to over the phone financial and treatment authorization.(Required)

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