First Appointment Questionnaire Ballard

First Appointment Questionnaire Ballard

Please take a moment to complete this brief questionnaire prior to your appointment.

First Appointment Questionnaire - Ballard
Name
Name
First
Last
Address
Address
Street
Apt / Suite
City
State
Zip
Preferred method of contact
How did you hear about us?
Would you like to add a secondary contact to the account?

Secondary Contact Information

Name
Name
First
Last

Pet Information

Maximum file size: 52.43MB

Species
Sex
Is your pet spayed or neutered?
(If unknown, approximate age)
Do you have previous medical records for your pet?

Maximum file size: 52.43MB

Has your pet seen a veterinarian before?
Does your pet have any allergies?
Is your pet currently taking any medications or supplements?
Does your pet have a microchip?
Are you interested in a microchip for your pet today?
Do you have pet insurance?
Why do we ask? We submit your claims for you after each visit!
Do you give a monthly heartworm preventative?
Would you like more information on Heartworm disease?
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?
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.
Does your cat go outside?
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Do other animals live in the household?

Authorizations

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 certify that I am the legal owner/agent of the above-mentioned pet(s) and I am hereby assuming all financial responsibility for treatment given to this animal by Heart of Chelsea Veterinary Group
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.
Do you consent to sharing photos of you and/or your pet on social media?
By selecting this option, I hereby grant Heart of Chelsea Veterinary Group permission to take photographs of myself and/or my pet and to publish those photographs for any lawful purpose, including, but not limited to, their website, and promotional materials, either digital or in print. I also grant permission to use my pet’s name. Heart of Chelsea Veterinary Group will remove any published photo(s) previously consented to at the owner’s request. I authorize Heart of Chelsea Veterinary Group to edit and share the aforementioned photograph(s). I also waive any rights of privacy or compensation associated with the use of my or my pet’s image(s) and name(s) for the personal or commercial purposes outlined above.

Signature