Pet Owner

Name *

First

Last

Spouse Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Type *

Home
Mobile
Work

Primary Phone *

Secondary Phone Type

Home
Mobile
Work

Secondary Phone

Email *

Preferred Contact Method *

How did you hear about our hospital? *

Whom may we thank for referring you? (they will receive a $10.00 credit for referring you)

If you selected other, please let us know how you heard about us

Patient Information

Pet *

Breed *

Sex *

Color *

Date of Birth or Age *

Number of pets in household (specify dogs, cats, or other species) * *

Pet Acquired From: *

Medical History

Previous Animal Hospital or DVM Name:

City of Previous Hospital

Phone (If known)

Do we have permission to contact for records? *

Yes
No

As a Fear Free Certified Professional team, we want to make your pet's veterinary experience as enjoyable and as stress-free as possible. It is helpful for us to understand what your pet might find upsetting. This information will help us to adjust our care to better serve and comfort your pet.

Does your pet show any reluctance to getting in the carrier or car? * *

Yes
No

How would you describe your pet’s reaction to going to the veterinary hospital? *

Eager and excited
Subdued
Reluctant
Somewhere in between

How would you describe your pet around other animals and people, such as in the lobby area of the veterinary hospital?

Dislikes seeing other dogs
Dislikes other pets approaching
Dislikes people passing by
Dislikes being approached by people
Dislikes loud noises/large groups

Are there things you or your pet did not like during past veterinary visits?

Has your pet ever been prescribed any medications or required sedation to help with a visit to the veterinary hospital? *

Yes
No

Does your pet or any member of your family have any FOOD ALLERGIES? *

Yes
No

We use many types of treats to make your pet's visit fun and positive. Please alert us immediately if we need to refrain from using specific ingredients (peanut butter, chicken/beef/fish, cheese, etc.)

Thank you for allowing us to care for your pet!

We are happy to provide an estimated cost for treatment plans upon request. GreenTree Animal Hospital accepts cash, personal checks, Visa/MasterCard, American Express, or Discover for payment. For payments by check, we will need the following information at the time of payment:

Driver's License
Issuing State
Expiration Date
Account Holder's Date of Birth
Employer's Name and Address

Please feel free to contact us at greentreevets@yahoo.com, or (847) 680-6543 with questions or to schedule/reschedule your pet's appointment.

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