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New Client Intake Form
Welcome to Coats Veterinary Hospital and thank you for choosing us for your pet’s care!
How did you hear about CVH?
Internet
Client/Friend/Relative
Location/Walk-In
Social Media (Facebook/Instagram)
Your current veterinary hospital (List the name and location of the veterinary hospital your pet last visited)
Do we have permission to call the previous veterinary hospital(s) for records for this pet?
Yes
No
Owner Name
First
Last
Spouse Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
Phone
Alternate Phone
Preferred Method of Contact
Call
Email
Text
Mail
For reminders
Call
Email
Text
Mail
Emergency Contact Name
First
Last
Emergency Contact Phone
Emergency Contact #2 Name
First
Last
Emergency Contact #2 Phone
Pet Information
Name
Species
Breed
Color
Birthdate
Date Format: MM slash DD slash YYYY
Sex
Male
Male Neutered
Female
Female Spayed
Is your pet microchipped?
Yes
No
Does your pet's lifestyle include any of the following?
Doggie Daycare
Boarding
Travel
Hunting
Hiking
Grooming
Swimming
Check all that apply.
Has your pet had any surgeries or previous serious illnesses?
Does your pet have any allergies (vaccine, food or medication)?
Is your pet currently on any medications (including heartworm and flea/tick prevention) or a special diet?
Does your pet have any health conditions or special requirements of which we should be aware?
Please list all other dogs and cats who live at your address below.
Please include name, species, breed, birthdate, color and sex. If you need additional space for this category, please email your list to: rapport@coatsvet.com.
Clients
Client Center
Forms
Rx/Food Refills
Payment Options
Contact
Request an Appointment
Health Certificates
About
Our Hospital
Meet Our Team
Employment Interest Form
Core Values
Location & Hospital Hours
Veterinary Services
Wellness Services
Medical Services
Surgical Services
Acupuncture
Preventive Services
End of Life
All Services
Resort & Spa Services
Resort & Spa Services
Cat & Dog Boarding
Bathing
Dog Grooming
Cat Grooming
Shop Online
Contact
facebook
instagram