We can’t wait to meet you! New Client Intake Form Welcome to Noah's Ark Veterinary & Boarding Resort. We are so pleased to have your family join ours! Please complete this form so that we may become better acquainted with and help you provide the best possible life for your pet. Step 1 of 5 20% Client InformationOwner's Information* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Primary Contact Number*Secondary Contact NumberE-Mail* Your e-mail information will be kept in strict confidence and will only be used to send you valuable health information. Please help us become a more "green" practice.Co-Owner's Name First Last Both parties may make equal medical and financial decisions regarding all pets listed. To remove a name from your account, we will need to speak to both parties.Primary Contact NumberSecondary Contact NumberE-Mail All account holders at Noah's Ark Veterinary & Boarding Resort must be at least 18 years of age. If you would like to add a person who can receive information regarding your pet (but not make medical or financial decisions), please list their information below: First Last How did you hear about us?* Friend/Family/Coworker Google Social Media Ad Newspaper Ad Magazine Ad Other Whom may we thank? Pet InformationName* Species* Breed* Birthdate (Minimally, year)* Color* Microchip Number Sex* Female Male Neutered/Spayed?* Yes No Vaccine/medication allergies or known reactions?** Yes No * Please list here*Chronic illness(es)?** Yes No * Please list here* What would you like your pet to be seen for? (Anything brought up during appointment may result in any quoted appointment price changing.)*Any coughing/sneezing/vomiting/diarrhea?* Coughing Sneezing Vomiting Diarrhea No Explain:*Normal urination/defecation?* Yes No Explain:*Normal mobility/activity level?* Yes No Explain:*Normal eating/drinking?* Yes No Explain:*If there is a history of seizures, date & length of last seizure & frequency: Diet (Brand, type, amount, & frequency)*Medications (If yes, list dose, frequency, and if refill is needed)*Lifestyle* Indoor Outdoor Daycare Boarding Grooming Dog Parks If boarding/daycare, at Noah's Ark?* Yes No Heartworm Control* Simparica Trio Heartgard Sentinel Interceptor Plus Revolution - K9 Revolution Plus Revolution Frontline Gold Advantage Other None What heartworm control are you using?* Date of last dose & is refill needed?* Flea/Tick Control* Simparica Trio Nexgard Simparica Frontline K9 Advantix Seresto Revolution Plus Revolution Frontline Gold Advantage Other None What flea/tick control are you using?* Date of last dose & is refill needed?* Fear Free Patient Care GoalWe are committed to using fear free techniques and would appreciate greatly if you filled out the Fear Free Visit Form located on the same page as this form for each patient prior to your visit.Practicing fear free handling includes giving high-value treats like peanut butter and cheese. Do we have your consent to give your pet these treats?:* Yes No Do you have another pet you'd like to tell us about?* Yes No Name* Species* Breed* Birthdate (Minimally, year)* Color* Microchip Number Sex* Female Male Neutered/Spayed?* Yes No Vaccine/medication allergies or known reactions?** Yes No *Please list here*Chronic Illness(es)?** Yes No *Please list here*What would you like your pet to be seen for? (Anything brought up during appointment may result in any quoted appointment price changing.)*Any coughing/sneezing/vomiting/diarrhea?* Coughing Sneezing Vomiting Diarrhea None If yes, explain: Normal urination/defecation?* Yes No If no, explain: Normal mobility/activity?* Yes No If no, explain: Normal Eating/Drinking?* Yes No If no, explain: If there is a history of seizures, date & length of last seizure & frequency: Diet (Brand, Type, Amount, & Frequency)*Medications (If yes, list dose, frequency, and if refill is needed)*Lifestyle* Indoor Outdoor Daycare Boarding Grooming Dog Parks If boarding/daycare, at Noah's Ark? Yes No Heartworm Control* Simparica Trio Heartgard Sentinel Interceptor Plus Revolution - K9 Revolution Plus Revolution Frontline Gold Advantage Other Date of last dose and is refill needed?* Flea/Tick Control* Simparica Trio Nexgard Simparica Frontline K9 Advantix Seresto Revolution Plus Revolution Frontline Gold Advantage Other Last Dose Given & is Refill Needed* Do you have another pet you'd like to tell us about?* Yes No Name* Species* Breed* Birthdate (Minimally, year)* Color* Microchip Number Sex* Female Male Neutered/Spayed?* Yes No Vaccine/medication allergies or known reactions?** Yes No *Please list hereChronic Illness(es)?** Yes No *Please list hereWhat would you like your pet to be seen for? (Anything brought up during appointment may result in any quoted appointment price changing.)*Any coughing/sneezing/vomiting/diarrhea? Coughing Sneezing Vomiting Diarrhea None If yes, explain:Normal urination/defecation?* Yes No If no, explain:Normal mobility/activity level?* Yes No If no, explain:Normal eating/drinking?* Yes No If no, explain:If there is a history of seizures, date & length of last seizure & frequency: Diet (brand, type, amount, & frequency)*Medications (list dose, frequency, and if refill is needed)*Lifestyle* Indoor Outdoor Daycare Boarding Grooming Dog Parks If boarding/daycare, at Noah's Ark? Yes No Heartworm Control* Simparica Trio Heartgard Sentinel Interceptor Plus Revolution - K9 Revolution Plus Revolution Frontline Gold Advantage Other Last dose given & is refill needed? Flea/Tick Control* Simparica Trio Nexgard Simparica Frontline K9 Advantix Seresto Revolution Plus Revolution Frontline Gold Advantage Other Last dose given & is refill needed? Prior Records Drop files here or Select files Max. file size: 256 MB. Please upload records for all pets listed. We cannot offer appointment times or create you an account without prior records. If no prior records exist, upload anything here to proceed through this.Is Your Pet Camera Ready?*We love to show off your pets! Do we have permission to use your pet's photos on our social media pages, website and other publications? Yes No Can We Share Your Pet's Records?*If your pet ever needs a veterinary specialist or visits another practice, they sometimes request medical records. Do we have permission to provide them if requested? Yes No Payment PolicyAll fees are due at the time services are rendered. As your veterinary care team, brief out-of-office communications in the form of email, text or phone calls, are part of our commitment to you. A consultation fee is incurred when changes in specialist availability to you results in the need for our doctors to do in-depth research, or preparation and communication with specialists. Estimates will gladly be provided upon request. We accept all major credit cards, cash, care credit, scratch pay, and checks. There is a $25 service charge for returned checks/chargebacks and automatic $5 billing fee applied to balances open at end-of-month.Cancellation PolicyWhen a patient cancels without giving enough notice, they prevent another patient from being seen. It is very important that you arrive on time to ensure that each pet and owner receives the time and care that they deserve. Those arriving late will be asked to reschedule their appointment(s). Please call us at 410-969-0100 ext. 3 by 1pm on the day prior to your scheduled appointment to notify us of any changes or cancellations. To cancel a Monday appointment, please call our office by 12pm the Saturday prior. If proper notification is not given, you will be charged a $35 fee per missed appointment/$75 fee per missed surgery.By signing below you consent to these terms:Signature* NameThis field is for validation purposes and should be left unchanged.
