630-699-3113
service@thewelcomewaggin.com
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Please Note: We will be closed on Tuesday, December 24th and Wednesday, December 25th in observance of Christmas!
New Pet and Client Intake Form
Please fill out this form before your first appointment.
APPOINTMENT
7
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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
--- Select state ---
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
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?
*
Family Member
The Branch -- Moms Group
Friend/acquaintance
Cruise Nights
Chamber Events
Coworker
Veterinarian
Pet Professional (groomer, pet sitter)
Local Business
Business Card Display
Online Search
Google Ad
Yelp
Newspaper/Magazine
Facebook
Instagram
TikTok
Other
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
Comment
Submit