New Patient Intake Form

Welcome to Coats Veterinary Hospital and thank you for choosing us for your pet’s care!

Owner Name
First Last
Spouse Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Alternate Phone
Preferred Method of Contact
For reminders
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
Is your pet microchipped?
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?

Pet Information