Hit enter to search or ESC to close
New Clients
About Us
Meet Our Team
Patient Photo Gallery
Services
Surgery
Canine Rehabilitation
Ultrasound
Patient Resources
Intro to Surgery
Price Sheet (Surgery)
Price Sheet (Rehab)
Post-Operative Instructions
Helpful Videos
Online Forms
New Client Registration Form
Recheck Intake Questionnaire – Surgery
Recheck Intake Questionnaire – Ortho
Intake Questionnaire – Consult
Contact Us
New Client Registration Form
Thank you for considering our clinic as your pet’s provider of surgical and rehabilitation veterinary services. We provide the highest level of service to our clients and their pets.
If your pet's condition has been diagnosed by your primary care veterinarian or a veterinary emergency hospital please contact them and request medical records, diagnostics including blood work and x-rays, be submitted to
[email protected]
Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
Owner's Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Day-Time Phone
*
What type of phone is this?
*
mobile/cell
work
home
Email
*
Co-owner's Information
Name
First
Last
Phone
How did you find out about our practice?
*
Vet or Hospital Referral
Personal Referral
Internet Search / Website
Social Media: Facebook, Yelp, Twitter, etc.
Print Media: Yellow Pages, etc.
Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Breed (if known)
Color
Date of Birth or Age (if known)
Weight (in pounds)
*
Please enter a number from
1
to
300
.
Sex
*
Neutered Male
Spayed Female
Male
Female
Unknown
Special Identification (tattoo, microchip, etc.)
Primary Veterinarian (clinic name, if any)
Is your pet current with rabies vaccination?
*
Yes
No
Is your pet on any medications or supplements?
*
Yes
No
If Yes, please list the medication or supplement
Does your pet have allergies or drug reactions?
*
Yes
No
If Yes, please list the allergies and reactions
Please tell us why you are requesting a surgical consult with Dr. Lewis.
*
Has this condition been diagnosed by your primary veterinarian, or by a specialty or emergency hospital?
*
Yes
No
If Yes, which hospital or clinic diagnosed your pet's condition?
Were x-rays taken?
*
Yes
No
If x-rays were taken, were they done under sedation?
Yes
No
I don't know
Date of these x-rays
Date Format: MM slash DD slash YYYY
Has your pet had blood work performed in the past 3 weeks? (do not include if done just for heartworms)
*
Yes
No
I don't know
Any history of seizures?
*
Yes
No
If "Yes" to seizures, please explain here.
Is your pet typically comfortable at the veterinarian? If no, please explain.
*
New Clients
About Us
Meet Our Team
Patient Photo Gallery
Services
Surgery
Canine Rehabilitation
Ultrasound
Patient Resources
Intro to Surgery
Price Sheet (Surgery)
Price Sheet (Rehab)
Post-Operative Instructions
Helpful Videos
Online Forms
New Client Registration Form
Recheck Intake Questionnaire – Surgery
Recheck Intake Questionnaire – Ortho
Intake Questionnaire – Consult
Contact Us
