CCVS Client Registration

New Client/Patient Form

Client/Pet Owner Name

Title

Physical Address

Mailing address (Only if different than Physical address)

Client/Owner Date of Birth:

YYYY

Cell Phone

Work Phone

Home Phone

Were you prompted to contact our facility?

No, this is a self-referral.

Yes, my Veterinarian referred me.

Select the best fit:

Name of Veterinarian & Name of Clinic/Animal Hospital that referred you:

Their address

Their phone number

Their FAX number

Their Email address

THIS NEXT SECTION IS ABOUT YOUR PET:

Pet Patient Information

Pet's Name:

Species:
Pet is a:

Canine

Feline

Sex:

Male

Female

Unknown

Pet's Breed/Color

Spayed or Neutered?

Yes

Unknown

Is your pet Microchipped?

Yes

Unknown

VACCINATION INFORMATION (DOG):

If Canine: DHPP was administered when?

VACCINATION INFORMATION (CAT):

If Feline: FVRCP was administered when?

RABIES:

1 Year Vaccination

3 Year Vaccination

Not sure

Date of Rabies vaccination:

In your own words, please describe your pet's problem, symptoms, or issue that is prompting this referral. (You will also have a chance to upload a photo(s) prior to submitting this form, if you think it will help us understand the issue.)

Please list pertinent history, long-term medical problems, or any major illnesses/accidents or surgeries?

History: Please indicate if there has been any recent occurrences of any of the issues listed below.

Vomiting

Diarrhea

Coughing

Sneezing

Itchiness

Lameness

Hair Loss

Discharge

Growths

Seizures

Exercise changes

Weight changes

Appetite changes

Behavior changes

Urinary Changes

NONE OF THESE

Known Allergies?

Current medications?

If your pet has previously been to a veterinarian, we will need to obtain these records. Please indicate how you would like them to get to us:

Please request them on my behalf from the referring Vet...

I can upload them with the submission of this form.

My pet has not been to a veterinarian before.

Please request them on my behalf from the Veterinarian/Animal Hospital listed in the next box (They were not involved in this referral).

Veterinarian/Animal Hospital that will have medical records needed for this referral (Both Name and Phone numbers should listed here):

Upload Pet's records here:

Delete all uploads

Choose files or drag here

The following has already been completed before this referral (check as many as needed):

Bloodwork

None

Echocardiogram (Mobile or Images)

Other:

X-rays

This form can also serve to request an appointment from us. Please show how we can best accommodate you (check as many as needed):

Looking for first available appointment.

I will be calling you. Just keep this form handy.

Please call me to answer questions or discuss appointment options

Other:

May we ask how you heard about our facility? (If 'Other', please specify)

My Veterinarian

A Friend/Family Member

A Local Non-Profit

Internet or Google Search

Radio

Other:

If a person, name of person or facility, so that we have the opportunity to thank them!

Do we have permission to take a photo of your pet for use in our social media? (You can choose multiple answers here)

Sure!

Yes! Feel free to use my favorite photo of him/her. I will upload it in this next form field.

No, but thank you for asking.

Other:

Yes, but let me approve the photo that your staff takes (via text) before doing so, please.

Please upload any photos here (either your pet's photo for social media, and/or photos of your pet's (condition/issue), as mentioned earlier in this form:

Delete all uploads

Choose files or drag here

Is this visit for a pre-surgery consultation?

(If yes, we have some additional questions to answer for this visit.)

Yes

What pain medications does your pet currently take? Please indicate drug name, the dosage (mg), and frequency and time of day that you administer each medication(s):

EXAMPLE: Previcox, 25 mg, each morning and night.

Please answer the following questions using the Numerical Scoring: Scale of 1-5

1. No problem

2. Little problem

3. Moderate problem

4. Difficult

5. Impossible

Does your pet walk up or down stairs?

1 - No problem

2 - Little problem

3 - Moderate problem

4 - Difficult

5 - Impossible

Does your pet jump on or off furniture?

1 - No problem

2 - Little problem

3 - Moderate problem

4 - Difficult

5 - Impossible

Does your pet 'climb down', instead of jump off furniture?

1 - No problem

2 - Little problem

3 - Moderate problem

4 - Difficult

5 - Impossible

Does your pet have difficulty laying down?

1 - No problem

2 - Little problem

3 - Moderate problem

4 - Difficult

5 - Impossible

How does your pet rise after a long rest?

1 - No problem

2 - Little problem

3 - Moderate problem

4 - Difficult

5 - Impossible

When is your pet most active?

Afternoon

Has your pet's play time decreased in duration or frequency?

1 - In frequency only

2 - In duration only

3 - In both

4 - No change

INTERACTION:

How often is your pet eager to play?

Has your pet's interaction with people or housemates decreased?

What is your pet's response to petting?

When you pet a certain body part, does your pet flinch, snap, growl, hiss, or end the interaction?

APPETITE:

Has your pet's appetite increased or decreased?

Has his/her positioning to eat/drink changed?

Have you had to raise the food or water bowl?

RESTING:

Is your pet restless at night?

Does your pet repeatedly lick a body part at night?

Can your pet sleep through the night?

ELIMINATING:

Has your pet's posture while eliminating changed?

Does your pet vocalize while eliminating?

Do you have home videos/photos for examples? If so, upload here:

Delete all uploads

Choose files or drag here

What is your perception of your pet's overall quality of life?

1 - Enthusiastic

4 - Anxious

2 - Comfortable

5 - Distressed

3 - Content

Electronic signature (1):

Treatment Consent: My signature below allows the Veterinarian to prescribe, diagnose and treat the described pet(s) for the agreed-upon services to the best of their abilities. I assume responsibilities for all charges incurred in the care of this animal. With my signature I acknowledge that medical information will not be released to anyone except for those indicated on this form. After an exam and upon request the hospital staff will provide any client with a written treatment plan prior to services being rendered. No payment plans are offered at this time. My signature below indicates my agreement with this policy.

Electronic signature (2):

Financial Consent- We accept Cash, Visa, MasterCard, Discover, CareCredit, and Scratch Pay. Full payment is due at the time of service. Clients with payment concerns are asked to speak to a Client Service Representative before their pet(s) exam. After an exam and upon request the hospital staff will provide any client with a written treatment plan prior to services being rendered. No payment plans are offered at this time. My signature below indicates my agreement with this policy.

Since you have selected ER/Critical Care for the primary reason for your visit, please call (352) 225-3501 immediately to let us know your plan, estimated time of arrival, etc, so we can be best prepared for this visit!

Date

2025