Patient Registration

Please schedule an appointment before filling out the New Patient Registration form below.

Owner's Name(Required)

First

Last

Address(Required)

Street Address

City

State / Province / Region

ZIP / Postal Code

Primary Phone(Required)

Email Address(Required)

Alternate Contact

Phone

Alternate Contact Email

Relationship

Demographics

Pet's Name(Required)

Species(Required)

Breed(Required)

Neutered/Spayed(Required)

Unaltered Male

Neutered Male

Unaltered Female

Spayed Female

Gender(Required)

Male

Female

Unknown

Date of birth/approximate age(Required)

Color(Required)

Other pets at home(Required)

Date acquired and source (pet store, breeder, previous owner, etc)(Required)

Names of Previous Veterinarian and Emergency/Specialty Veterinary Clinics (If any)(Required)

Per Illinois law, does a court ordered ownership agreement apply to this animal?(Required)

Yes

Are you or your significant other active or retired military?(Required)

Yes

Environment

Is the animal kept indoors or outdoors?(Required)

Indoors

Outdoors

Combination

Describe the cage enclosure – type, size objects in the cage (dust baths, toys, etc)

What material is used to line the bottom of the cage/litter pan?

Is the animal kept in a cage with other animals?(Required)

Yes

If you answered yes to the previous question, how many cage-mates are there? What sex are the cage-mates? Are the cage-mates spayed/neutered?

Please list all other pets in the household (species)

Have there been any new pets (within the past six months) placed in this animal's cage?

How much time does your pet spend outside of the cage?

Is your pet supervised when it is out of the cage?

At all times

Sometimes

Not supervised

Does your pet chew on carpet or other objects/materials when outside of the cage?

List any recent changes in the environment, if any:

Diet

What amount of your pet’s diet consists of the following (please describe what the animal actually eats, not what it is offered)

Type of Food

Amount of Hay (Timothy, Alfalfa, etc)

Amount of Pellets (Timothy, Alfalfa, etc)

Amount of Seeds (type/brand)

Amounts of Vegetables (types)

Amount of Fruit (types)

How often do you change your pet's food?

What (if any) treats do you give your pet (brand and amount)

Do you supplement your pet with any vitamins? (brand and frequency)

Is the food or water supplemented with vitamins (brand and frequency)

Please describe any recent change to your pet's diet

Reproductive

Has this pet been bred before? If yes, how many times?

When was it last bred?

What was the size of all previous litter(s)?

Was the litter healthy?

Reasons for Visit

Is your pet here for a well pet check-up or is it sick?(Required)

Well Pet

Sick Pet

If your pet is sick, please describe the signs and how long your pet has been showing these signs

Is your pet's activity level(Required)

Normal

Decreased

Increased

Is your pet's appetite(Required)

Normal

Decreased

Increased

Have you noticed any of the following

Weight Loss

Weight Gain

Discharge from the eyes or nose

Increased breathing rate or efforce

Change in the droppings

An increased or decreased thirst

Weakness

Weight Loss Details(Required)

Weight Gain Details(Required)

Discharge from the eyes or nose details(Required)

Increased breathing rate or efforce details(Required)

Change in the droppings details(Required)

An increased or decreased thirst details(Required)

Weakness details(Required)

Previous Conditions: Has your pet had any previous conditions, operations, or problems (including dental or gastrointestinal problems)

Is your pet currently on any medications (name, frequency)

Has your pet been on any medications recently? If yes, please list them.

Is there anything else that you would like done for your pet today?

Nail Trim

Ear Cleaning

Mat Trimming

I hereby state that the information is true and correct to the best of my knowledge. I further agree that if I am not the owner or responsible party that I may still be held responsible to provide payment for any services that I order or authorize.

Owner Signature(Required)

Date(Required)

MM slash DD slash YYYY

We like to thank our clients who refer friends and family to us. How did you hear about our hospital?(Required)

(Internet, drive by, name of friend or family member, etc)

Pocket Pet and Bird Intake Form – Reg

Patient Registration

Demographics

Environment

Diet

Reproductive

Reasons for Visit

Get in touch

(847) 548-2626

Business Hours

(847) 548-2626