Name *

First

Last

Email *

Primary Phone *

Can you send/receive texts from this number? *

Yes
No

Secondary Phone

Can you send/receive texts from this number? *

Yes
No

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please upload a current picture of your pet(s) to be added to their patient records.

Click or drag a file to this area to upload.

Instructions - cross streets, house color, cars, etc. that will help us find your home:

Who else is authorized to make decisions about your pet's health care?

First

Last

Phone

How did you hear about us? *

If you were referred by someone else, who should we thank?

Pet's Name *

Species *

Dog
Cat
Other

Please specify: *

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Color/Markings *

Age/Date of Birth *

Does your pet have a microchip identification? *

Yes
No

Microchip Number *

Would you like to add a second pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

Please specify: *

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Color/Markings *

Age/Date of Birth *

Does your pet have a microchip identification? *

Yes
No

Microchip Number *

Would you like to add a third pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

Please specify: *

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Color/Markings *

Age/Date of Birth *

Does your pet have a microchip identification? *

Yes
No

Microchip Number *

Previous Veterinarian or Previous Vet Clinic's Name

Phone

Can you help us gather updated records from your previous veterinarian?

Yes
No

In order for our doctors to best examine your pet(s) we need to learn their medical history. Please send us a copy of their complete medical history, including DVM notes, diagnostic images and reports, surgical reports, prescription history, and a vaccination certificate. Records can be sent to us by email at service@thewelcomewaggin.com or fax at 331-333-3058.

How may we help you?

Wellness Visit for Annual/Semi-Annual check up including vaccines and lab work
Illness Visit
Quality of Life/Hospice Planning and/or End of Life Care

May we help you with aftercare for your pet?

Communal (no ashes returned to you)
Private (ashes returned to your veterinarian)
Traditional/flame-based
Aquamation
Home burial/managing body care and will not need cremation services

If your pet is 35-90 pounds, do you have one person who can safely help lift your pet on a stretcher? If your pet is over 90 pounds, do you have two people who can safely help lift your pet on a stretcher? (We may be able to provide an extra person with enough notice.)

Yes
No
My pet weighs less than 35 pounds.

Do we have your authorization to post a memorial about your pet? Your pet's first name and an included photo would be the only identifier.

Yes
No

Tell us a little about your pet's issue: *

Photo & Video Approval

I hereby authorize The Welcome Waggin and its representatives to take photographs of my pet(s) during veterinary visits. I understand that these photographs may be used for marketing purposes, including but not limited to social media, websites, and printed materials. I further understand that no identifying information, including my pet's name, will be used without my consent.

I waive any right to inspect or approve the finished product, including written or electronic copy, wherein my pet's likeness appears. I also waive any right to royalties or other compensation arising or related to the use of the photographs.

I acknowledge that I am not entitled to any compensation for the use of these photographs and that I am not obligated to sign this waiver as a condition of receiving veterinary services.

Please check consent box below.

Yes, I agree. The Welcome Waggin can take photos of my pet and share them on our public social media pages.
No, please don't take photos of my pet.

By checking below, I certify that I am the owner and or agent of the above animal and have the authorization to consent to treatment if and when it is needed. I have also read and agree to the "What to Expect" page information and policies. *

I agree

New Pet and Client Intake Form

Photo & Video Approval

Quality care in the comfort of your home.

Contact Info

SAY HELLO

Ready for a home visit?