New Patient Form

Please remember to arrived at least 10 minutes before your appointment time.

Date of your appointment*

This helps us to make sure we have all your information correct before your appointment.

Owners first and last name:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone*

Cell Phone*

Work Phone*

How did you hear about us?

Referral
Our website
Sign
Internet
Coupon
Magazine

If it was a referral, we would like to thank them.

Let us know who we can send a Thank You card too.

Number of dogs in your household

Number of cats in your household

Other pets in household?

Reason for visit.*

Give a brief description of your pets needs today.

I Hereby authorize the veterinarians of BVH to examine, prescribe for, and/or treat the described pet(s). I assume all financial responsibility for charges incurred in the care of my pet(s). I understand that all charges must be paid, in full, at the time of release. BVH accepts cash, credit card or Care Credit for new clients. At any point BVH may request a deposit for treatment services while my pet(s) are in the care of BVH. By signing this document I agree and authorized all of the above and will allow BVH to release my pet(s) records to other hospitals and/or specialist as needed.

Authorized Signature*

Do you have copies or access to your pets past records?*

Yes
No

Please provide name and number of clinic.*

If you do not know the phone number please provide as much information so we can do internet research. If your pet doesn't have a medical history, type N/A.

Pet's name.*

What type of pet?*

Dog
Cat

If not listed select 'other' and fill in.

Gender*

Male
Neutered male
Female
Spayed female

Breed*

If not sure of breed use "Mixed" If cat use DSH (Domestic Short Hair), DMH or DLH.

Birthdate*

Color*

Please check all presenting problems you have noticed with your pet.*

If other please explain.

If your pet is on any medications, please list.*

Column 1	Column 2	Column 3

If you need to list more than 3 items, click on the "+" to add. Please list the brand, if your pet is on monthly Heartworm and/or flea prevention.

Reactions or allergies to vaccines or medications?*

Vaccine allergies
Reactions to medications
No

If yes to one or both of the above please explain.

Describe your pet's diet.*

Type of food (dry/wet/combo of both). How often fed in a day and amount.

Do you have more than one pet we will be seeing today?*

Yes
No

Pet's name.*

What type of pet?*

Dog
Cat

If not listed select 'other' and fill in.

Gender*

Male
Neutered male
Female
Spayed female

Breed*

If not sure of breed use "Mixed" If cat use DSH (Domestic Short Hair), DMH or DLH.

Birthdate*

Color*

Do you copies or access to your pets past records?*

Yes
No

If no, please provide name and/or number of clinic we can call.*

If you do have records type in "Have records"

Please check all presenting problems you have noticed with your pet.*

If your pet is on any medications, please list.*

Column 1	Column 2	Column 3

If you need to list more than 3 items, click on the "+" to add. List if your pet is on monthly Heartworm and/or flea prevention.

If other please explain.

Reactions or allergies to vaccines or medications?*

Vaccine allergies
Reactions to medications
No

If yes to one or both of the above please explain.

Describe your pet's diet.*

Type of food (dry/wet/combo of both)

Monday	7:00am – 6:00pm
Tuesday	7:00am – 6:00pm
Wednesday	7:00am – 6:00pm
Thursday	7:00am – 6:00pm
Friday	7:00am – 6:00pm
Saturday	8:00am – 1:00pm
Sunday	Closed

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BVH New Patient Form

Please remember to arrived at least 10 minutes before your appointment time.

New Clients

Pet Health

Survey/Reviews page

New Patient Form

BVH New Patient Form

Please remember to arrived at least 10 minutes before your appointment time.

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New Clients

Pet Health

Survey/Reviews page