Owner Name: *

First

Last

Spouse Name:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone:

Email *

Employer:

Work Phone:

How did you learn about us?

Is it ok to post a picture of your pet on our Facebook page?

Yes
No

Pet Information

Pet's Name: *

Pet's Date of Birth: *

Species: *

Canine
Feline
Other

If other, please specify: *

Breed: *

Color:

Sex:

Female
Male
Neutered
Spayed

Brand of food offered?

Canned
Dry
Both

Treats given?

Yes
No

Is table food offered?

Yes
No

Real bones?

Yes
No

Is your pet?

Indoor
Outdoor
Both

Is heartworm and/or flea prevention currently used?

Yes
No

Any prescription or over counter medications given at this time?

Yes
No

Does your pet frequent a boarding kennel, grooming salon, dog park or socialize with other pets?

Yes
No

Reason for today's visit:

Prescription Policy as of 08/01/2024:

Veterinary Associates WILL NOT process (phone, email, fax, etc.) prescriptions to or from outside and online pharmacies (with the only exception being for medications that need to be compounded).

We support our client's choice to choose where they obtain their pet's medications and are happy to accommodate a request to do so.

Clients who opt to obtain their pet's medication through these avenues will need to pick up a physical written prescription at our hospital with 2 business days' notice.

Please refer to our prescription policy on our website or you may request a physical copy from our staff.
By signing here, I acknowledge that I have read and agree to the above stated prescription policy:

Signature: *

Clear Signature

Today's Date: *

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Pet Information

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