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New Patient Form

Please complete the form below BEFORE YOUR FIRST VISIT

Name of Human Guardian

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Main Phone Number

(###)

###

####

Secondary Phone

(###)

###

####

Email Address

General Practitioner Veterinarian (doctor and practice names)

Today’s date

YYYY

Pet's Name

Breed

Age / DOB

Sex

Spayed / Neutered

Color / Markings

Weight

When is your scheduled appointment with Dr. Tsakiris?

How did you hear about our practice?

Referral

Reason for Today’s visit and date of onset of current history

Specify your goals for treatment

Other Current Problems

Past medical issues (dates)

Vaccine history

Please provide specific dates and blood work results (bring copies or have them emailed):

Current medications and supplements

Current and Past Diet

How is your pet's appetite? how many times a day do you feed them?

Does you pet prefer cool (hard wood floor or tile) or warm areas (sunny spots) of the house

How would you describe your pet's energy level?

How would you describe your pet's thirst?

What is your pet's exercise routine? walks? hikes? backyard? runs around the house?

Is your pet easily stressed? What are stressors for your pet? thunderstorms? leaving the house? people coming to the door? etc

I understand there are 2 update emails included with each visit. I understand that I will be charged for Dr. Tsakiris's time beyond this for emails as well as phone communication. I understand followup appointments are required.

I agree