Have you had symptoms consistent with COVID-19 (e.g., fever, cough, new loss of taste or smell) within the last ten days? *

Have you tested positive for COVID-19 within the last ten days?

Within the last fourteen days, have you had close contact (i.e., within 6 feet for 15 minutes or longer) with someone who has symptoms consistent with COVID-19? *

When our staff interacts with you in person, are you okay with us wearing the normal mask and gloves, or would you prefer if we wore full PPE?

Mask and gloves is fine
Please wear full PPE when interacting with me

Name of authorized owner *

First

Last

Spouse

First

Last

Street address *

e.g. 2150 W. Liberty

City *

State *

ZIP *

e.g. 48103

Phone number *

e.g (734) 662-4474

Email *

Driver's license # *

(This is required by the DEA)

State issued *

e.g. Michigan, Ohio, etc.

Your date of birth *

(This is required by the DEA)

Patient/pet name *

Species *

Dog
Cat
Other

Breed *

Date of birth

If you don't know, give your best guess)

Age *

If you don't know, give your best guess)

Color *

e.g. brown, black and white, etc.

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

Additional patients/pets

If you have more than one pet, please enter their information here in a similar format (e.g. "Rex, dog, Chocolate Lab, born 4/15, age 5, brown color, neutered male")

Previous veterinarian

Please provide your previous veterinarian's name and phone number so we can have your pet's medical records faxed to us (i.e. vaccine history, heartworm testing, etc.)

Additional caretaker

If desired, you may provide the name and phone number of one other person (trusted friend, family member, etc.) you authorize to order treatment or obtain patient information.

Authorization for treatment *

Please authorize treatment by entering your name and today's date in the box above. You are authorizing the release of your pet's medical records and will assume responsibility for all fees incurred. Note: All professional fees are due at the time services are rendered. Monies owed for services not paid at the time services are rendered are subject to billing fees and interest.

New Client and Patient Form