New Patient Form – Whitestone Animal Hospital

Primary Person on Account *

First

Last

Phone *

Email *

What is the best way to contact you? *

Email
Phone

Address *

Address Line 1

City

State

Zip Code

Additional Person on Account

First

Last

Phone

Doctor Preference(s)

Appointment Date Preference

This is not a guarantee for this date.

Appointment Time Preference

Morning
Afternoon

This is not a guarantee for this time slot.

Which is most important for this visit?

Doctor preference
Date and time preference

Pet Species *

Dog
Cat
Other

Please specify *

Pet's Name *

Pet's Age or Date of Birth *

Pet's Breed & Color *

Pet's Sex *

Male
Female
Neutered Male
Spayed Female

Previous Vet Hospitals your pets have been seen at. Please include Name/City/State

Do we have permission to get your pet's records?

Yes
No

Does your pet have any allergies to food, environment, or medications/vaccinations? (Note: We commonly use peanut butter, cream cheese, Cheerios as treats)

Yes
No

Please explain.

What kind of food is your pet eating? (Brand/Type)

Has your pet had any previous surgery or medical conditions?

Yes
No

Please explain.

Tell us about your pet's personality at the vet... shy, nervous, friendly, aggressive? What has worked well in the past to make your pet more comfortable at the vet hospital?

Do we have permission to use pictures of your pet on social media or our website?

Yes
No

Do you have an additional pet you'd like to add? *

Yes
No

Pet Species *

Dog
Cat
Other

Please specify *

Pet's Name *

Pet's Age or Date of Birth *

Pet's Breed & Color *

Pet's Sex *

Male
Female
Neutered Male
Spayed Female

Previous Vet Hospitals your pets have been seen at. Please include Name/City/State

Do we have permission to get your pet's records?

Yes
No

Does your pet have any allergies to food, environment, or medications/vaccinations? (Note: We commonly use peanut butter, cream cheese, Cheerios as treats)

Yes
No

Please explain.

What kind of food is your pet eating? (Brand/Type)

Has your pet had any previous surgery or medical conditions?

Yes
No

Please explain.

Tell us about your pet's personality at the vet... shy, nervous, friendly, aggressive? What has worked well in the past to make your pet more comfortable at the vet hospital?

Do we have permission to use pictures of your pet on social media or our website?

Yes
No

Please state pet's name & reason for appointment:

If sick, how long have the symptoms been going on?

What are the symptoms?

Current medications/supplements?

What kind of food is your pet eating? (Brand/Type)

Is your pet taking a heartworm preventative?

Please list three potential dates and time frames that you would like to make your appointment for. (A member of our staff will follow up to confirm your appointment date & time) * *

How did you hear about us?

Did someone refer you?

Yes
No

Who may we thank?

New Patient Information