Preferred Location *

Chelsea
Lower East Side
Hell's Kitchen

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Mr.
Mrs.
Ms.
Mx.

Name *

First

Last

Address *

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Email *

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Preferred method of contact *

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Referred by:

How did you hear about us?

If Other, please explain:

Pet's Name *

(additional pets can be added further down this form)

Species *

Canine
Feline

Date of birth (if unknown, approximate age) *

Breed *

Color *

What is the reason for today’s visit?

Please list any past medical problems or surgical history *

Please upload any of your pet's records that you may have

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

Does your pet have any allergies? *

Yes
No

If yes, please list: *

Is your pet currently taking any medications or supplements? *

Yes
No

What medications or supplements is your pet taking? *

What brand or type of food do you feed your pet? *

Does your pet have a microchip? *

Yes
No
Unsure

Are you interested in a microchip for your pet today? *

Yes
No
I would like more information on microchips

Do you have pet insurance? *

Yes
No

Provider *

Policy Number

Why do we ask? We submit your claims for you after each visit!

Do other animals live in the household? *

Yes
No

Please list any additional pets and/or species of animals in the household. *

Does your cat go outside? *

Yes
No

Is your dog vaccinated for Canine Flu H3N8/H3N2? *

Yes
No

Would you like more information on the Canine Bivalent Flu vaccine?

Yes
No

Canine Influenza H3N8 & H3N2 are contagious respiratory diseases caused by the influenza virus. It is spread by direct contact through the air during coughing, sneezing or contaminated objects. Recent outbreaks have become more common in the United States among unvaccinated dogs. Clinical signs may include fever, nasal discharge, lethargy, coughing and decreased appetite.

Would you like to discuss the Bivalent Flu vaccine with your doctor?

Yes
No

Do you travel often outside of the city with your pet in the northeastern United States? *

Yes
No

Is your pet vaccinated against Lyme disease? *

Yes
No

Would you like more information on Lyme disease and prevention?

Yes
No

Lyme disease is caused by a spirochete called Borrelia burgdorferi. A spirochete is a type of bacterium. It is transmitted to dogs through the bite of a tick. Once in the bloodstream, the Lyme disease organism is carried to many parts of the body and is likely to localize in joints. It was first thought that only a few types of ticks could transmit this disease, but now it appears that several common species may be involved. The most common type of tick to carry Lyme disease is the Deer Tick. A vaccine is now available for protecting dogs against Lyme disease. This vaccine is initially given twice, at two-week intervals. Annual revaccination is also necessary to maintain immunity. The vaccine has been shown to be safe and very effective.

Would you like to discuss the Lyme vaccine with your doctor?

Yes
No

Does your pet drink out of standing water, puddles or streams? *

Yes
No

Is your pet vaccinated against Leptospirosis? *

Yes
No

Would you like more information on Leptospirosis and prevention?

Yes
No

Leptospirosis is a bacterial disease of dogs and other mammals that particularly affects the liver or kidneys. Leptospira bacteria are carried mainly by rats and other rodents, but can also affect almost any mammalian species, including people. Infected or recovered “carrier” dogs can also act as a source of the infection. Ingestion of infected urine or rodent-contaminated garbage is the most common means of transmission, but some forms of the bacteria can penetrate damaged or thin skin. For instance, when dogs swim in contaminated water, they may become infected through their skin. The incubation period (from infection to onset of clinical signs) is usually 4-12 days.

Would you like to discuss the Lepto vaccine with your doctor?

Yes
No

Do you give a monthly heartworm preventative? *

Yes
No

What monthly preventative do you give? *

Would you like more information on Heartworm disease? *

Yes
No

Heartworm disease is a serious disease that results in severe lung disease, heart failure, organ damage, and possibly death in dogs, cats, and ferrets. It is caused by a parasitic worm called Dirofilaria immitis. The worms are spread through the bite of a mosquito. The dog is the definitive host, meaning that the worms mature into adults, mate, and produce offspring while living inside a dog. The worms are called “heartworms” because the adults live in the heart, lungs, and associated blood vessels of an infected animal. We recommend year-round heartworm prevention options which include monthly oral medications or long-acting injectable medication.

Are you interested in an injectable preventative called ProHeart that can protect your pet from Heartworm for 12 months? *

Yes
No

ProHeart is an injectable parasiticide that is used in dogs 12 months of age and older to prevent heartworm disease. It offers a year of protection with one dose administered annually. It is a safe and effective alternative to monthly oral medications.

Would you like to complete the questionnaire for a second pet? *

Yes
No

Pet's Name *

Species *

Canine
Feline

What is the reason for today’s visit?

Please list any past medical problems or surgical history *

Does your pet have any allergies? *

Yes
No

If yes, please list: *

Is your pet currently taking any medications or supplements? *

Yes
No

What medications or supplements is your pet taking? *

What brand or type of food do you feed your pet? *

Does your pet have a microchip? *

Yes
No
Unsure

Are you interested in a microchip for your pet today? *

Yes
No
I would like more information on microchips

Do you have pet insurance? *

Yes
No

Provider *

Policy Number

Does your cat go outside? *

Yes
No

Is your dog vaccinated for Canine Flu H3N8/H3N2? *

Yes
No

Would you like more information on the Canine Bivalent Flu vaccine?

Yes
No

Canine Influenza H3N8 & H3N2 are contagious respiratory diseases caused by the influenza virus. It is spread by direct contact through the air during coughing, sneezing or contaminated objects. Recent outbreaks have become more common in the United States among unvaccinated dogs. Clinical signs may include fever, nasal discharge, lethargy, coughing and decreased appetite.

Would you like to discuss the Bivalent Flu vaccine with your doctor?

Yes
No

Do you travel often outside of the city with your pet in the northeastern United States? *

Yes
No

Is your pet vaccinated against Lyme disease? *

Yes
No

Would you like more information on Lyme disease and prevention?

Yes
No

Lyme disease is caused by a spirochete called Borrelia burgdorferi. A spirochete is a type of bacterium. It is transmitted to dogs through the bite of a tick. Once in the bloodstream, the Lyme disease organism is carried to many parts of the body and is likely to localize in joints. It was first thought that only a few types of ticks could transmit this disease, but now it appears that several common species may be involved. The most common type of tick to carry Lyme disease is the Deer Tick. A vaccine is now available for protecting dogs against Lyme disease. This vaccine is initially given twice, at two-week intervals. Annual revaccination is also necessary to maintain immunity. The vaccine has been shown to be safe and very effective.

Would you like to discuss the Lyme vaccine with your doctor?

Yes
No

Does your pet drink out of standing water, puddles or streams? *

Yes
No

Is your pet vaccinated against Leptospirosis? *

Yes
No

Would you like more information on Leptospirosis and prevention?

Yes
No

Leptospirosis is a bacterial disease of dogs and other mammals that particularly affects the liver or kidneys. Leptospira bacteria are carried mainly by rats and other rodents, but can also affect almost any mammalian species, including people. Infected or recovered “carrier” dogs can also act as a source of the infection. Ingestion of infected urine or rodent-contaminated garbage is the most important means of transmission, but some forms of the bacteria can penetrate damaged or thin skin. For instance, when dogs swim in contaminated water, they may become infected through their skin. The incubation period (from infection to onset of clinical signs) is usually 4-12 days.

Would you like to discuss the Lepto vaccine with your doctor?

Yes
No

Do you give a monthly heartworm preventative? *

Yes
No

What monthly preventative do you give? *

Would you like more information on Heartworm disease? *

Yes
No

Heartworm disease is a serious disease that results in severe lung disease, heart failure, organ damage, and possibly death in dogs, cats, and ferrets. It is caused by a parasitic worm called Dirofilaria immitis. The worms are spread through the bite of a mosquito. The dog is the definitive host, meaning that the worms mature into adults, mate, and produce offspring while living inside a dog. The worms are called “heartworms” because the adults live in the heart, lungs, and associated blood vessels of an infected animal. We recommend year-round heartworm prevention options which include monthly oral medications or long-acting injectable medication.

Are you interested in an injectable preventative called ProHeart that can protect your pet from Heartworm for 12 months? *

Yes
No

(copy)

Check this box to view more information on ProHeart

ProHeart is an injectable parasiticide that is used in dogs 12 months of age and older to prevent heartworm disease. It offers a year of protection with one dose administered annually. It is a safe and effective alternative to monthly oral medications.

Would you like to complete the questionnaire for a third pet? *

Yes
No

Pet's Name *

Species *

Canine
Feline

What is the reason for today’s visit?

Please list any past medical problems or surgical history *

Does your pet have any allergies? *

Yes
No

If yes, please list: *

Is your pet currently taking any medications or supplements? *

Yes
No

What medications or supplements is your pet taking? *

What brand or type of food do you feed your pet? *

Does your pet have a microchip? *

Yes
No
Unsure

Are you interested in a microchip for your pet today? *

Yes
No
I would like more information on microchips

Do you have pet insurance? *

Yes
No

Provider *

Policy Number

Does your cat go outside? *

Yes
No

Is your dog vaccinated for Canine Flu H3N8/H3N2? *

Yes
No

Would you like more information on the Canine Bivalent Flu vaccine?

Yes
No

Canine Influenza H3N8 & H3N2 are contagious respiratory diseases caused by the influenza virus. It is spread by direct contact through the air during coughing, sneezing or contaminated objects. Recent outbreaks have become more common in the United States among unvaccinated dogs. Clinical signs may include fever, nasal discharge, lethargy, coughing and decreased appetite.

Would you like to discuss the Bivalent Flu vaccine with your doctor?

Yes
No

Do you travel often outside of the city with your pet in the northeastern United States? *

Yes
No

Is your pet vaccinated against Lyme disease? *

Yes
No

Would you like more information on Lyme disease and prevention?

Yes
No

Lyme disease is caused by a spirochete called Borrelia burgdorferi. A spirochete is a type of bacterium. It is transmitted to dogs through the bite of a tick. Once in the bloodstream, the Lyme disease organism is carried to many parts of the body and is likely to localize in joints. It was first thought that only a few types of ticks could transmit this disease, but now it appears that several common species may be involved. The most common type of tick to carry Lyme disease is the Deer Tick. A vaccine is now available for protecting dogs against Lyme disease. This vaccine is initially given twice, at two-week intervals. Annual revaccination is also necessary to maintain immunity. The vaccine has been shown to be safe and very effective.

Would you like to discuss the Lyme vaccine with your doctor?

Yes
No

Does your pet drink out of standing water, puddles or streams? *

Yes
No

Is your pet vaccinated against Leptospirosis? *

Yes
No

Would you like more information on Leptospirosis and prevention?

Yes
No

Leptospirosis is a bacterial disease of dogs and other mammals that particularly affects the liver or kidneys. Leptospira bacteria are carried mainly by rats and other rodents, but can also affect almost any mammalian species, including people. Infected or recovered “carrier” dogs can also act as a source of the infection. Ingestion of infected urine or rodent-contaminated garbage is the most important means of transmission, but some forms of the bacteria can penetrate damaged or thin skin. For instance, when dogs swim in contaminated water, they may become infected through their skin. The incubation period (from infection to onset of clinical signs) is usually 4-12 days.

Would you like to discuss the Lepto vaccine with your doctor?

Yes
No

Do you give a monthly heartworm preventative? *

Yes
No

What monthly preventative do you give? *

Would you like more information on Heartworm disease? *

Yes
No

Heartworm disease is a serious disease that results in severe lung disease, heart failure, organ damage, and possibly death in dogs, cats, and ferrets. It is caused by a parasitic worm called Dirofilaria immitis. The worms are spread through the bite of a mosquito. The dog is the definitive host, meaning that the worms mature into adults, mate, and produce offspring while living inside a dog. The worms are called “heartworms” because the adults live in the heart, lungs, and associated blood vessels of an infected animal. We recommend year-round heartworm prevention options which include monthly oral medications or long-acting injectable medication.

Are you interested in an injectable preventative called ProHeart that can protect your pet from Heartworm for 12 months? *

Yes
No

(copy) (copy)

Check this box to view more information on ProHeart

ProHeart is an injectable parasiticide that is used in dogs 12 months of age and older to prevent heartworm disease. It offers a year of protection with one dose administered annually. It is a safe and effective alternative to monthly oral medications.

Would you like to complete the questionnaire for a fourth pet? *

Yes
No

Pet's Name *

Species *

Canine
Feline

What is the reason for today’s visit?

Please list any past medical problems or surgical history *

Does your pet have any allergies? *

Yes
No

If yes, please list: *

Is your pet currently taking any medications or supplements? *

Yes
No

What medications or supplements is your pet taking? *

What brand or type of food do you feed your pet? *

Does your pet have a microchip? *

Yes
No
Unsure

Are you interested in a microchip for your pet today? *

Yes
No
I would like more information on microchips

Do you have pet insurance? *

Yes
No

Provider *

Policy Number

Does your cat go outside? *

Yes
No

Is your dog vaccinated for Canine Flu H3N8/H3N2? *

Yes
No

Would you like more information on the Canine Bivalent Flu vaccine?

Yes
No

Canine Influenza H3N8 & H3N2 are contagious respiratory diseases caused by the influenza virus. It is spread by direct contact through the air during coughing, sneezing or contaminated objects. Recent outbreaks have become more common in the United States among unvaccinated dogs. Clinical signs may include fever, nasal discharge, lethargy, coughing and decreased appetite.

Would you like to discuss the Bivalent Flu vaccine with your doctor?

Yes
No

Do you travel often outside of the city with your pet in the Northeastern United States? *

Yes
No

Is your pet vaccinated against Lyme disease? *

Yes
No

Would you like more information on Lyme disease and prevention?

Yes
No

Lyme disease is caused by a spirochete called Borrelia burgdorferi. A spirochete is a type of bacterium. It is transmitted to dogs through the bite of a tick. Once in the bloodstream, the Lyme disease organism is carried to many parts of the body and is likely to localize in joints. It was first thought that only a few types of ticks could transmit this disease, but now it appears that several common species may be involved. The most common type of tick to carry Lyme disease is the Deer Tick. A vaccine is now available for protecting dogs against Lyme disease. This vaccine is initially given twice, at two-week intervals. Annual revaccination is also necessary to maintain immunity. The vaccine has been shown to be safe and very effective.

Would you like to discuss the Lyme vaccine with your doctor?

Yes
No

Does your pet drink out of standing water, puddles or streams? *

Yes
No

Is your pet vaccinated against Leptospirosis? *

Yes
No

Would you like more information on Leptospirosis and prevention?

Yes
No

Leptospirosis is a bacterial disease of dogs and other mammals that particularly affects the liver or kidneys. Leptospira bacteria are carried mainly by rats and other rodents, but can also affect almost any mammalian species, including people. Infected or recovered “carrier” dogs can also act as a source of the infection. Ingestion of infected urine or rodent-contaminated garbage is the most important means of transmission, but some forms of the bacteria can penetrate damaged or thin skin. For instance, when dogs swim in contaminated water, they may become infected through their skin. The incubation period (from infection to onset of clinical signs) is usually 4-12 days.

Would you like to discuss the Lepto vaccine with your doctor?

Yes
No

Do you give a monthly heartworm preventative? *

Yes
No

What monthly preventative do you give? *

Would you like more information on Heartworm disease? *

Yes
No

Heartworm disease is a serious disease that results in severe lung disease, heart failure, organ damage, and possibly death in dogs, cats, and ferrets. It is caused by a parasitic worm called Dirofilaria immitis. The worms are spread through the bite of a mosquito. The dog is the definitive host, meaning that the worms mature into adults, mate, and produce offspring while living inside a dog. The worms are called “heartworms” because the adults live in the heart, lungs, and associated blood vessels of an infected animal. We recommend year-round heartworm prevention options which include monthly oral medications or long-acting injectable medication.

Are you interested in an injectable preventative called ProHeart that can protect your pet from Heartworm for 12 months? *

Yes
No

(copy) (copy) (copy)

Check this box to view more information on ProHeart

ProHeart is an injectable parasiticide that is used in dogs 12 months of age and older to prevent heartworm disease. It offers a year of protection with one dose administered annually. It is a safe and effective alternative to monthly oral medications.

Additional questions or comments:

Appointment Information

Due to increased safety measures and adherence to social distancing and other COVID-19 guidelines, entrance by clients into the hospital is limited to appointments that are scheduled with a doctor. Entrance for only those appointment types is available but remains optional. If you choose to enter our office, we ask that only one pet parent come in and masks are mandatory and to be worn throughout the duration of your visit.

Hospital-Wide Hygiene Briefings

As an AAHA accredited hospital, Heart of Chelsea already subscribes to best practice veterinary maintenance and safety protocols. To further diminish COVID-19 risks, all hospital staff have received updated briefings on operational safety recommendations from the CDC. Our team members have all been instructed to stay home and seek appropriate care if they are sick.

Advanced Air Filtration

With the ability to reduce 99% of all microbes in a sneeze before they travel 3 feet, we hope to offer a little more peace of mind with our Advanced Air Filtration System and our existing protocols as we begin to allow clients back into our hospitals.

Watch this video for more information on Advanced Air Filtration technology.

Click here for covid-19 UPDATES

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of my pet(s). I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospital treatment. *

I have read and agree

I hereby authorize the release of my pet’s medical records to another facility (boarding/daycare, insurance company, urgent care facility, etc.), should they be requested. *

Yes
No

Signature *

Date *

First Appointment Questionnaire

Appointment Information

Hospital-Wide Hygiene Briefings

Advanced Air Filtration

Authorization