Type of Client

New Client
Urgent Care
Oral Care

First Visit Free does not apply to Urgent Care Patients. First Visit Free is only for new patients transferring to Dr. DeForge's General Practice, Silver Sands Veterinary.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Preferred method of contact *

Call
Text
Email

Name of Previous Veterinarian

Previous Veterinary Phone

Previous Veterinary Email

Previous Veterinary Website

How did you hear about us? *

If other, please specify *

Whom may we thank for the referral? *

Please note: Your privacy is important to us. All information received in all forms and through other communications is subject to our Patient Privacy Policy.

Pet Information

Pet's Name *

Species *

Dog
Cat
Other

Is your cat *

Indoor Only
Indoor-Outdoor
Mostly Outdoor

If other, please specify *

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Age/Date of Birth *

DATE OF LAST RABIES VACCINATION *

Current Weight in lbs. *

Please describe your pet's diet (brand, food type, and amount fed per day) *

Please describe your pet's previous medical history *

Please list your pet's vaccination history *

Please list any medication/supplements your pet is taking (name, dosage, frequency) *

History of any Sedation/Anesthesia Adverse Reaction-Please describe in detail *

Current heartworm preventative *

Current flea/tick preventative *

Any recent behavioral changes? *

Yes
No

If yes, please explain *

Does your pet have any know allergies/reactions to vaccines? *

Yes
No

If yes, please explain *

Add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Current Weight *

Age/Date of Birth *

Please describe your pet's diet (brand, food type, and amount fed per day) *

Please describe your pet's previous medical history *

Please list your pet's vaccination history *

Please list any medication/supplements your pet is taking (name, dosage, frequency)

Current heartworm preventative *

Current flea/tick preventative *

Any recent behavioral changes? *

Yes
No

If yes, please explain *

Does your pet have any know allergies/reactions to vaccines? *

Yes
No

If yes, please explain *

Add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Current Weight *

Age/Date of Birth *

Please describe your pet's diet (brand, food type, and amount fed per day) *

Please describe your pet's previous medical history *

Please list your pet's vaccination history *

Please list any medication/supplements your pet is taking (name, dosage, frequency)

Current heartworm preventative *

Current flea/tick preventative *

Any recent behavioral changes? *

Yes
No

If yes, please explain *

Does your pet have any know allergies/reactions to vaccines? *

Yes
No

If yes, please explain *

Add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Current Weight *

Age/Date of Birth *

Please describe your pet's diet (brand, food type, and amount fed per day) *

Please describe your pet's previous medical history *

Please list your pet's vaccination history *

Please list any medication/supplements your pet is taking (name, dosage, frequency)

Current heartworm preventative *

Current flea/tick preventative *

Any recent behavioral changes? *

Yes
No

If yes, please explain *

Does your pet have any know allergies/reactions to vaccines? *

Yes
No

If yes, please explain *

Add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Current Weight *

Age/Date of Birth *

Please describe your pet's diet (brand, food type, and amount fed per day) *

Please describe your pet's previous medical history *

Please list your pet's vaccination history *

Please list any medication/supplements your pet is taking (name, dosage, frequency)

Current heartworm preventative *

Current flea/tick preventative *

Any recent behavioral changes? *

Yes
No

If yes, please explain *

Does your pet have any know allergies/reactions to vaccines? *

Yes
No

If yes, please explain *

Reason for visit *

Please upload any necessary paperwork (medical history, vaccine history, etc.)

Click or drag files to this area to upload. You can upload up to 10 files.

All payments are due at the time of services rendered. *

I have read and understand the above statements and agree to all terms therein

I authorize medical treatment as deemed necessary and appropriate by the Silver Sands Veterinary Walk-In Urgent Care Veterinary Physician[s] and their professional staff participating in my pet’s care.

I will provide all necessary information related to my pet’s healthcare needs that may affect the treatment I may receive, including but not limited to; past medical history, past and current medications, and current medical issues.

I understand that if I do not provide all necessary information pertaining to my pet’s current health, that I will not hold the providers or other employees of Silver Sands Walk-In Veterinary Urgent Care liable for any adverse reactions.

With my consent, Silver Sands Veterinary Walk-In Urgent Care may use and disclose Protected Health Information (PHI) about my pet to carry out treatment, payment, and healthcare operations.

With my consent, Silver Sands Veterinary Walk-In Urgent Care may email, text, APP Chat, or call my home or other designated location[s] and leave a message in reference to any items that assist the practice in carrying out treatment, payment, or healthcare operations, such as appointment reminders, insurance items and any call[s] pertaining to my pet’s clinical care, including laboratory results and diagnostic results.

This shall serve as notice that NOT all medical services are available or performed at Silver Sands Veterinary Walk-In Urgent Care that is deemed necessary for the treatment or diagnosis of the patient and determined by our Veterinary Providers as necessary or in the best interest of the management of your pet’s condition and any services that may be required at other specialized facilities or at your Local Doctor of Veterinary Medicine on re-examination after Urgent Care.

Any emergency care that the attending veterinary urgent care physician believes should, in the best interest of the patient, be provided by another Facility will not be the financial responsibility of Silver Sands Veterinary Walk-In Urgent Care. A referral to another specialty service or facility will be done in the best interest of the patient, and Silver Sands Veterinary Urgent Care has no financial interest in referral facilities or specialist referrals. Patients are expected to follow up with their primary care physician for continued medical management unless otherwise noted by Silver Sands Veterinary Walk-In Urgent Care and in no way acts or represents itself as a primary care provider.

The client-pet owner understands that the list below is provided as an example of services outside the scope of urgent care practice for Silver Sands Veterinary Walk-In Urgent Care and does not include all of the services that may be considered to require specialized care beyond the treatment that is provided at Silver Sands Veterinary Walk-In Urgent Care.

Exclusions to Walk-In Urgent Care may include life-threatening events such as heart attacks; cardiopulmonary collapse; stroke and vascular accidents; poisonings that need 24/7 care after treatment; major wound trauma and/or complex compound fractures; life-threatening spinal-vascular-gastrointestinal-or urinary problems; coughing blood or severe blood loss leading to shock; auto accidents that require critical care; pulmonary embolism; life-threatening chest and abdominal trauma; grand mal seizures; ocular trauma; serious septic infections; cardiopulmonary collapse or shock; hospitalizations; and treatment with other veterinary specialists; subspecialists, or providers at another healthcare organization.

Clients must agree to see a specialist veterinary physician when a medical problem is outside the scope of Silver Sands Veterinary Walk-In Urgent care or for pre-existing conditions requiring a specialist as determined by our veterinary urgent care practitioners. Patients with complicated medical conditions (i.e., diabetes, heart failure, seizure disorder, cancer, etc.) will be required to continue to follow up with their generalist/specialist based on recommendations from urgent care. The veterinary physician[s] at Silver Sands Veterinary Walk-In Urgent will work in conjunction with the specialist to ensure quality care, follow-up care, and medicine refills when appropriate.

I have read and understand the above statements and agree to all terms therein

I certify that I am the owner of the pet listed above. I certify that I am financially responsible for all veterinary fees. I certify that I am 18 years of age or older.

Certifico que soy el dueño de la mascota mencionada anteriormente. Certifico que soy financieramente responsable de todos los honorarios veterinarios. Certifico que tengo 18 años de edad o más.

Ownership and age certification *

I certify the above statement

Signature *

Date *

New Client Form

Please complete this form before your visit.

Pet Information

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