New Client Form

Please select from the following*

Name*

First Last

Spouse or Secondary Contact

First Last

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address (If different from mailing address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone or Alternative Phone*

Work Phone

Email*

Are you over the age of 18?*

Yes
No

Do you have a scheduled appointment?*

Yes
No

Appointment Date*

Appointment Time*

:

How did you hear about us? (Check all that apply)

Phonebook
Our Website
Google/Internet

Did someone refer you?*

Yes
No

(If yes, may we ask who referred you?)

Date and Initials

Please indicate today's date*

Please enter your initials to indicate you have read the below statement*

Professional fees are due at the time services are rendered. At your request we will gladly discuss cost of services and/or prepare a written estimate for recommended procedures.

We accept cash, checks, debit cards, VISA, MasterCard, Discover, American Express and Care Credit. A $25.00 service fee will be charged for all returned checks.

To prevent the spread of infectious diseases and parasites, we recommend that all pets be current on all vaccines. Pets with fleas or ticks will be treated with a topical medication on admission, and the prescription price will be included on the invoice. I authorize administration of parasite and infectious disease control as needed for my pet(s).

Patient Information

Your pet's name*

Species*

Canine
Feline

Breed*

Sex*

Female
Female Spayed
Male
Male Neutered

Your pet's birthdate or age*

Color/Marking*

Patient Medical History

Current medications and dosages*

If none, please indicate.

When were medications last given?*

If not applicable, please indicate as such

Vaccinations

Please provide dates of last vaccination if known:

Do you have your pets Rabies Vaccination information?*

I have my pets rabies vaccination info
I do not have my pets rabies vaccination info

Rabies Vaccination Date

Do you have your pets Distemper-Parvo Vaccination information?*

I have my pets distemper-parvo vaccination info
I do not have my pets distemper-parvo vaccination info

Distemper-Parvo Vaccination Date

Do you have your pets Feline Upper Respiratory Vaccination information?*

I have my pets feline upper respiratory vaccination info
I do not have my pets feline upper respiratory vaccination info

Feline Upper Respiratory Vaccination Date

Do you have your pets Feline Leukemia Vaccination information?*

I have my pets feline leukemia vaccination info
I do not have my pets feline leukemia vaccination info

Feline Leukemia Vaccination Date

Other medical history

Has your pet had unusual/unexpected reactions to medications or vaccines?*

Yes
No

If yes, what did your pet react to?

Is your pet now taking preventative for heartworm disease?*

Yes
No

If yes, what is the name of the medication?

Has your pet been treated for any major medical problems?*

Yes
No

If yes, what type and when?

Has your pet ever undergone any type of surgery, other than neutering?*

Yes
No

If yes, what type of surgery and when?

Diet and lifestyle

What types of food do you currently feed your pet?*

How much food do you feed your pet?*

How often do you feed your pet?*

Is your pet an indoor/outdoor pet, or both?*

Indoor
Outdoor

Is your pet in a home with multiple animals?*

Yes
No

Do you board your pet frequently?*

Yes
No

Does your pet go to a groomer frequently?*

Yes
No

Has your pet traveled out of New Mexico recently?*

Yes
No

If yes, when and where?

Are there any other medical or behavioral issues that your veterinarian should know about?

Name

This field is for validation purposes and should be left unchanged.

Gruda Veterinary Hospital

Services

Laser Therapy

Routine and Preventive Care

Surgery and Orthopedics

Dentistry

Endoscopy

Ultrasound

Oncology

Acupuncture

Chiropractic

In-House Laboratory

Emergency Care

About

Contact

Resources

Our App

Store

New Client

Referrals

Emergency

New Client Information - Copy 1

Date and Initials

Patient Information

Patient Medical History

Vaccinations

Other medical history

Diet and lifestyle

We are located at 9 Rumble Road in Santa Fe, NM.

Contact Us

Hours

Monday - Friday

Saturday