Client Forms Available Online | Back Bay Veterinary Clinic

New Patient Registration

Patient Registration Form

Date

Name

First

Last

Address

City

State/Province

Zip/Postal

Primary Contact Number

Phone type

Home

Cell

Work

Email

Co-owner/Emergency Contact

First

Last

Co-owner Phone Number

Pet's Name

Species

Canine

Feline

OtherOther

Date of Birth

Breed

Color

Sex

Male

Male/Neutered

Female

Female/Spayed

Do you have Pet Insurance?

Yes

No

If so, what kind?

Name of most recent Veterinarian seen

I authorize the Back Bay Veterinary Clinic to obtain my pet's medical history from my previous veterinarian

I authorize

Your Pet's Current Medication(s)

Your Pet's Current Diet

I hereby authorize the veterinarian and Back Bay Veterinary Clinic to examine, prescribe for, or treat the above described pet. I will assume responsibility for all charges incurred for the care of this animal. I also understand that these charges will be paid at completion of service or time of release and that a deposit may be required for surgical and/or in-hospital treatments.

I authorize

Name of Owner

First

Last

Date

How did you find out about our clinic?

Internet

Yellow Pages

Referral

OtherOther

Payment Options: American Express, Cash, Master Card and Visa only. Thank you.

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Medical Record Release

Request for Medical Record Release

Name

First

Last

Email

Pet's Name

I am requesting a copy of my pet's medical record to be released from the Back Bay Veterinary Clinic.

I am requesting

Please note this request may take up to 72 hours to process

Signature

Clear

Date

Current Address

City

State/Province

Zip/Postal

Current Phone

Reason for Request

Select one of these options

I will pick up the records at the Back Bay Veterinary Clinic

I request the records to be sent to me at the above address

I request the records to be faxed to me

I request the records to be emailed to me

Fax number to send to

Email address to send to

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International Travel Questionnaire

Name

First

Last

Email

Pet's Name

Name of person traveling with pet (as it appears on passport)

Date of arrival at your destination

Origination address (in US)

City

State/Province

Zip/Postal

Origination phone number

Destination address

City

State/Province

Zip/Postal

Country

Destination phone number

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Medical Proxy Authorization

Name

First

Last

Address

City

State/Province

Zip/Postal

Email

Phone

Patient

Species

Breed

Sex

Color

Weight

I, the above named owner of the above named animal, authorize the following third party to make medical decisions for my pet in the event I cannot be reached.

I authorize

Name of pet medical proxy

Phone number of medical proxy

Proxy's relationship to me

Friend

Family member

Pet sitter

OtherOther

I understand that payment is due at time of services rendered and have provided my proxy with the resources to cover the cost of care. In the event of unforseen circumstances wherein payment cannot be rendered immediately, I assume all financial responsibility related to my pet's medical treatment and payment will be rendered directly to Back Bay Veterinary Clinic as soon as reasonably possible.

I understand

Signature

Clear

Date

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Pre-visit Client Questionnaire

Reptile Husbandry Questionnaire

Small Mammal History/Intake Form

Sedated Procedure Consent Form

Euthanasia Authorization Form

Anesthesia/Surgical Procedure Consent Form

Avian Husbandry Questionnaire

Preventative Exam Form

Name

First

Last

Email

Patient's Name

What diet is your pet currently eating?

What preventatives is your pet taking monthly for heartworm, flea, and tick prevention?

Please list any medications and supplements (including dosages and frequency).

How is your pet's mobility (any limping, problems jumping, up/down stairs, etc)?

Any new or growing lumps or bumps?

Yes

No

If yes, include information about size and location, and when first noticed.

Any recent vomiting, diarrhea, coughing or sneezing?

Yes

No

If yes, include information about frequency.

Any known allergies?

Any changes to the amount your pet is drinking or urinating?

Do you do anything at home for dental health?

Has your pet had any previous vaccine reactions?

Any other concerns you would like to discuss with the doctor during the exam?

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