Owner Information

Owner's Name *

First

Last

Spouse’s Name *

First

Last

Cell Phone Number

Other Phone Number

Can you receive text messages? *

Yes
No

Email Address *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who may we thank for referring you to our office?

Pet Information

Pet's Name *

Animal Type *

Dog
Cat

Age/Birthdate *

Years/Months Owned *

Breed *

Color *

Sex *

Male
Female

Intact/Not Intact? *

Intact
Not Intact

Brand of food? *

How often do you feed your pet? *

How much do you feed your pet? *

Current Medications

Current over the counter medications

Are you using flea/tick control? *

Yes
No

If yes, what brand?

Are you using heartworm prevention? *

Yes
No

If yes, what brand?

Past History

Which clinic may we contact for previous history? *

Has your pet had any prior illnesses, accidents, or surgeries? *

Yes
No

Please explain.

Is your pet protective of you, aggressive towards other animals, or uncomfortable with restraint? *

Yes
No

Please explain. *

Does your pet have any known allergies to any medications? *

Yes
No

If yes, please list: *

Has your pet ever had a vaccine reaction? (Vomiting, facial swelling, hives) *

Yes
No

If yes, please list and explain: *

Is your pet food or toy motivated? *

Yes
No

If yes, please list and explain: *

Office Policies

To allow for ample time for all patients and surgical procedures, Pet Health Center operates primarily by appointment. We request all our clients be on time for scheduled appointments and procedures. If you are 15 minutes late to your appointment, you may be asked to reschedule your appointment. We do take emergencies; however, these services may be subject to a higher fee schedule. For your convenience, we offer limited same-day appointments for urgent care sick patients. They fill up fast, so we recommend calling first thing in the morning.  

For your protection, and that of others, pets should be properly restrained by a leash or carrier upon arrival. If your pet requires special accommodations, please give us a call when you arrive so we can assist you and your pet.  

If you must cancel an appointment, we ask for 24-hours’ notice. For surgical appointments, we ask for a 48-hour cancellation notice. You may be subject to a no-show fee or a deposit for any future appointments if you do not notify us of a cancellation.

We accept cash, debit, or all credit cards. We also offer CareCredit financing to help make the highest quality of care accessible to all our patients.

I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet. I assume responsibility for all charges incurred in the care of this animal. *

I have read and agree.

I understand that payment is ALWAYS DUE IN FULL at time of service. A deposit of 50% of the treatment plan may be required before treatments or hospitalization of your pet. I recognize that financial concerns should be discussed PRIOR to examination and treatment. *

I have read and agree.

Do we have permission to share your pet’s image and story on our social media, website, and other forms of related media? *

Yes
No

I authorize my emergency contact (other than myself) to pursue treatments if I am unavailable. Your emergency contact must be an adult over the age of 18. *

I have read and agree.

Emergency Contact *

First

Last

Emergency Contact Phone *

Signature *

Clear Signature

Date *

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

New Client Form

New Clients

Owner Information

Pet Information

Past History

Office Policies

Pet care you can trust

636-447-4555

636-447-4555

[email protected]

Appointment

Say hello!

HOURS

Providing quality pet care

4045 North St. Peters Parkway, Suite 202
Saint Peters, MO 63304