"*" indicates required fields Your Name* Spouse/Partner's Name Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Number Cell Number* Spouse/Partner's Cell Phone Email Address How did you hear about us? Pet InformationNameBreedAgeSexSpayed/NeuteredMedicationsPrevious Vet Add RemoveSocial Media/Photo Permission:Do we have your permission to post photos of your pet online and/or use it for marketing purposes?* Yes No Owner Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY AuthorizationI hereby authorize the veterinarian to examine, prescribe for, and/or treat my pet(s). I assume responsibility for all charges incurred in the care of my pet(s). I also understand that charges are to be paid at the time of service.Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Fear Free FAS Pre-visit Questionnaire:As Fear Free certified professionals, we want to make your visit to our hospital the best it can be for you and your pet. If you have a few minutes, we would like for you to answer a few questions so we can take both you and your pets preferences for your first visit to our hospital. This short questionnaire will help us get to know your pet… A Fear Free visit starts at home! 1. Does your pet show any reluctance to get in the carrier or car?*YesNo2. How and where does your pet travel while in the car?*A. In the back seatB. In a crate or carrierC. Attached to a seatbeltD. Loose3. During travel to the veterinary hospital, does your dog do any of the following? (check all that apply)* A. Eager / Excited B. Subdued C. Reluctant D. Bark E. Hide F. Whine G. Drool H. Pant I. Vomit J. Tremble K. Urinate / defecate L. Pace M. None of the above 4. Does your pet prefer:*A. Female veterinary staffB. Male veterinary staffC. It does not matter5. Check any situations listed below that your pet has shown avoidance or dislike of in the past.* A. Entering the veterinary hospital B. Walking through the veterinary hospital C. Being weighed D. Being put up on the table for examination E. Other pets and/or people passing by while in reception/check-in F. Waiting with other people and animals in the waiting area G. Being approached by veterinary staff H. Getting on the scale for a weight I. Hearing the doorbell, overhead intercom, or phones ringing J. Going in the exam room K. Being taken out of the exam room for procedures L. Loud voices during examination M. The use of instruments such as the stethoscope or otoscope (look in ears) N. Having direct eye contact with the technician and/or veterinarian O. Having a rectal temperature taken P. Sounds coming from the back areas of the practice Q. None of the above 6. Briefly describe your pet around other animals and people, such as in the lobby area of a veterinary hospital?* 7. Does your pet have any sensitive areas that he/she does not like touched or examined by you or others? (i.e. paws, ears, tail, etc)* 8. What are your pet’s favorite treats? (We recommend you bring some to the visit!)* 9. Does your pet like to play with toys? If so, what kind? (We recommend you bring their favorite to the visit!)* 10. Has your pet ever been prescribed any medications to help with a visit to a veterinary hospital? If so, what medications were they and what results did you experience?* 11. Is your pet on these medications today?*
