New Patient Registration Owner(s)* First Last Spouse First Last D.L. # Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Residence PhoneHusband CellWife CellWhat is the best time to reach you? AM PM How did you become aware of our hospital? Yellow Pages Hospital Sign Google Facebook Other Personal Recommendation Whom may we thank? So that we are able to suit your individual needs - which do you feel most applies to you: Check One I feel that my pet is another member of our family. I feel that my pet is just a pet. Check OneCheck One I want the best medical care for my pet; please recommend anything you feel is necessary for good health. I want good medical care for my pet, but there is a limit to what I am able to have done. I want you to perform only the services I request. Check OneCheck One I want to learn as much as I can about pet health care, please explain in detail what has been done for my pet or what is needed. I would prefer you just summarize what has been done for my pet or what is needed. I want my pet healthy, but don't need to know what has been done. Check OneCheck One I would prefer to be present when my pet is examined and treated. I would rather not see my pet examined and treated. Check OneHow old was your pet when you acquired it? How many hours is your pet outside each day? What prior illness or surgery should we know about?Is your pet currently on a special diet or medication?What health care or grooming products are you currently using?List any known drug or food allergiesPet Information (Please fill in the following for each pet)Name, Breed, Color, Date of Birth (or estimated age), Spayed / Neutered, Male / FemaleEmergency Contact Name First Last PhoneClient's SignatureDate MM slash DD slash YYYY Team Member Admitting Feline Leukemia Virus: The Feline Leukemia Virus (FelV) is the leading viral killer of cats. it is estimated that fewer than 20% of infected cats will survive more than 3 years after being infected. Anemia (red blood cell deficiency which carries oxygen), cancer and secondary infections result from immune deficiency caused by FelV are the most common consequences of the infection, indoor/outdoor cats, cats ina multi-cat home, and cats that frequent lanais should be tests. If the test is negative they should be vaccinated for FelV. The initial dose is followed by a booster 2 weeks later, and then given annually.* I accept I decline Feline Bordetella: Bordetellosis Bronchiseptica is a bacterium that can cause disease of the respiratory tract in cats. Cats with bordetellosis may cough, have a runny nose and/or eyes, sneeze, occasionally have a fever, and decreased appetite. The signs of this disease are very similar to those caused by the feline herpesvirus and feline calicivirus. Cats are believed to become infected by breathing in the bacteria into their noses. Cats residing in or entering rescue shelter, multi-cat homes, and boarding facilities have the highest risk of exposure. Vaccination is recommended biannually if they are in group situations or intended to board. The infection is highly contagious to other cats and can persist for weeks.* I accept I decline Feline Heartworm Disease: Hearworms are transmitted by female mosquito bites. Dogs are the most commonly infected mammals. Mosquitoes feed on infected animals then transmit heartworm disease to cats, other mammals, and occasionally people. Common symptoms may include sporadic vomiting, which may or may not be related to eating and coughing which may be intermittent or occur in severe, sudden attacks. Cats may have severe, acute disease with respiratory collapse and sudden death. Outdoor cats are most at risk, but interestingly enough a new study of feline heartworm disease in Texas and South Carolina showed that 36% of infected cats were kept totally indoors. Since it takes so few of the heartworm parasites to cause disease in cats, even the occasional mosquito finding its way into the home can carry more than enough heartworm larvae to be fatal. Luckily, cats can now be put on a once a month preventative medication. We recommend that your cat be put on a once a month preventative, such as Advantage-Multi or Feline Heartgard.* I read and would like prevention I read and decline prevention Signature*Last Name Pet's Name Date MM slash DD slash YYYY Canine InfluenzaH3N8 and H3N2 Canine Influenza Virus, more commonly known as the dog flu, is a newly emerging infectious virus that infects dogs. The H3N8 is Specific to dogs whereas the H3N2 can infect cats and there is no evidence that in can Infect people at this time. All boarded dogs are at risk! K9 Flu Facts: Highly contagious among dogs. Reported in over 30 States, recent outbreak of H3N2 in Florida 5/31/17. Dogs have no immunity to the CIV virus. Virtually every dog exposed will become infected; any breed or age 80% of infected dogs will exhibit symptoms. The non-symptomatic pets will still spread the virus. Symptoms include Sneezing, nasal discharge, and coughing. Other symptoms include a low-grade fever, Inappetence, and lethargy. Severe symptoms include a high-fever, secondary pneumonia, and possibly death. Spread via direct contact or airborne, facilitating rapid spread. Dogs become more at risk when Participating in certain activities such as: Being adopted from a shelter/rescue/breeding facility/pet store Boarding or attending doggie day care Attending group training sessions Visiting a groomer Playing at dog parks or encountering other dogs while on walks Engaging with other dogs while at the veterinarian’s office or pet store Or any other activities where associating with other dogs Canine Influenza is a virus and should not be confused with Bordetella (Kennel Cough), which is a bacterial infection. The Canine Influenza Vaccine (CIV) has been proven to be an effective combatant against the spread and severity of canine influenza, H3N8 and H3N2, and is now recommended by the American Veterinary Medical Association (AVMA). Vaccinating is the only prevention. Initially, the vaccination is administered in two doses. The initial dose, followed by a booster 2 weeks later, then anually (Cost per dose is $47.00). If the second dose is not administered within the first 4 weeks of the first dose, it is recommended that the series be restarted. * I accept I decline Signature*Leptospirosis (Lepto): Leptospirosis (Lepto) is a potentially fatal bacterial disease that infects wildlife, domestic animals, and humans. It is the world’s more common zoonotic disease. Lepto is shed from urine of infected animals that can survive for months on soil and water surfaces such as lakes, ponds, streams, rivers, and stagnant water (puddles). With our yearly rain fall comes increased risk to your pet. On average 75% of the citrus rats that were trapped test positive for lepto. Lepto can cause fever, weight loss, vomiting, diarrhea, dehydration, abdominal pain, hepatic and renal dysfunction leading to failure. Highest prevalence of this disease is more common in the southeastern United States. We recommend vaccinating your pet against lepto. The initial dose is followed by a booster 2 weeks later, and then given annually (Cost per dose $20.00).* I accept I decline Borrelosis (Llyme disease): Lyme disease is a dangerous bacterial tick-borne disease that can affect both animals and humans and is found in nine species of ticks. The Lyme vaccine was developed to help protect dogs from the harmful bacteria that cause Lyme disease. A dog that has been fed on by an infected tick can develop this disease. All dogs are at risk. Even your inside dog can be exposed in their backyard, lanai, and on outdoor walks. Symptoms may be hard to detect but include lameness, swelling of joints or limbs, fever, and/or vomiting. We recommend vaccinating your pet against Lyme disease. The initial dose is followed by a booster 2 weeks later, and then given annually (Cost per dose $45.00). We test annually for Lyme disease for your pet’s protection. * I accept I decline Microchip: Each year millions of pets are lost. You can permanently identify your pet without a collar by microchipping. A small chip, about the size of a grain of rice, is inserted under the skin between the shoulder blades of your pet. The microchip provides your pet with its own numerical code. This code has a lifetime registration with no need for annual renewal. AS an additional service, you may activate a free lost pet medical insurance policy which covers medical care in case of an emergency if the pet is lost. A handheld scanner is passed over the pets shoulders and the numerical code is displayed by the scanner. The scanner is routinely used by veterinarians, officers, animal shelters, and animal control agencies across the county. We can microchip your pet today for $55.00.* I accept I decline Signature* Like Us On Facebook AppointmentsWe will do our best to accommodate your busy schedule. Request an appointment today! Request Appointment Our Location
