Gilbertsville Vet – Additional Pet Form

1
Congratulations on your new pet. Please fill in the information so that we can add your pet to our system and create their patient file. Please contact our office at (610) 367-4744 if you have any questions.
2
Date
First Name
Last Name
Email
Pet's Name
3
Male
Male Neutered
Female
Female Spayed
Sex
Birthday or Approximate Age
Canine
Feline
Avian
Ferret
Mouse/Rat/Rodent
Reptile/Amphibian
Rabbit
Gerbil/Guinea Pig/Hamster
Species
Breed
Color
Microchip or Permanent ID number
At what age was your pet when you obtained him/her?
Please list any allergies that your pet has:
4
What diet are you currently feeding your pet?
Friend
Breeder
Pet Shop
Humane Society
Other
Where did you obtain this pet?
If other, Please Specify
Yes, I authorize Gilbertsville Veterinary Hospital to take and use photos of my pet. I understand that these photos may be used on social media platforms, hospital marketing materials and the Gilbertsville Veterinary Hospital website.
No, I do not authorize Gilbertsville Veterinary Hospital to take or use photos of my pet.
Photo Authorization Form
Yes, I authorize Gilbertsville Veterinary Hospital to provide my pet's medical records to requesting third parties.
No, I do not authorize Gilbertsville Veterinary Hospital to release my pet's medical records to requesting third parties without my consent.
Medical Record Release
5
Does your pet have any special alerts that our team should be aware of? (for example: needs muzzle, does not like cats, does not like dogs, etc.)
6
Has your pet had any prior illness or surgical procedures in the past? Please describe.
Please list any medications that you pet is taking, if any.
Reason for your pet's visit? Please describe below.
7
Please list any questions or concerns that you have for our veterinarians or team members.
Previous Veterinary Facility name (if applicable):
Phone Number of Previous Veterinary Facility for us to call and request your pet's records (if applicable):
8
If you have vaccine records, you may upload a photo of them here.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
9
I am the said owner or the agent for the above described pet and have the authority to execute this consent. I understand that I will be responsible for the cost of veterinary services, prescriptions, and product at the time they are rendered for my pet. I have read and understand this authorization and consent by typing my name below.
First Name
Last Name
Should be Empty: