Gilbertsville Vet – New Client Form Old

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Gilbertsville Veterinary Hospital is pleased to welcome you to our practice. Please take a few minutes to complete this form as completely as you can. If you have any questions we'll be glad to help you. You can contact us at (610) 367-4744. We look forward to working with you in maintaining your pet's health.
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Date* This field is required.
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Your Name* This field is required.
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Address
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Other
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I do not have an email account
I have an email but prefer not to provide it at this time
Email Information
Email
This is a cell phone
This is a land line
Primary Phone Number
Phone Number
This is a cell phone
This is a land line
Secondary Phone Number
Phone Number
Hospital Sign
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Friend
Telephone Book
Pottstown Pet Fair
How did you hear about us?
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If you were referred by a friend please share their name with us so we can thank them.
First Name
Last Name
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Pet's Name * This field is required.
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* This field is required.
Male
Male/Nurtured
Female
Female/Spayed
Sex
Canine
Feline
Avian
Ferret
Mouse/Rat/Rodent
Reptile/Amphibian
Rabbit
Gerbil/Guinea Pig/Hamster
Species
Breed
Color
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Birthday or Approximate Age
Microchip or Permanent ID Number
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At what age was your pet when you obtained him/her?
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Please list any allergies that your pet has
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If other, Please Specify
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What are you currently feeding your pet?
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Where did you obtain this pet?
Friend
Breeder
Pet Shop
Humane Society
Other
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If other, Please Specify
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Photo Authorization Form
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.
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Medical Record Release
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.
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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.)
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Has your pet had any prior illness or surgical procedures in the past? Please describe.
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Please list any medications that your pet is taking, if any.
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Reason for your pet's visit? Please describe
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Please list any questions or concerns that you have for our veterinarians or team members.
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Previous Veterinary Facility name (if applicable)
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Phone Number of Previous Veterinary Facility for us to call and request your pet's records (if applicable)
Area Code
Phone Number
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If you have vaccine records, you may upload a photo of them here.
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Max. file size: 10.6MB
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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 signing below.
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