New Patient (Animal) Information Form
We require this basic information to treat your pet.
Owners Information
*
Owners First Name
Owners Last Name
Pet's Name
*
Species
*
Canine(Dog)
Feline(Cat)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Email
example@example.com
Pets BirthDate
*
-
Month
-
Day
Year
If unkown get as close as possible
Pet's weight
*
Weight in Pounds
Pet's Sex
*
Male
Female
Does your pet have any DRUG or FOOD allergies
*
Yes
No
Describe you Pet's Drug or Food allergies
Are you giving any other medications, prescription or over the counter to your pet?
*
Yes
No
If yes, please list the medications you are giving to your pet
Does your pet have any of these chronic health conditions?
*
High Blood Pressure
High Cholesterol
Diabetes
Thyroid Disorders
Glaucoma
Asthma
HIV
None of the above
Do wish "Child Resistant" lids on your containers
Yes
No
Back
Next
Lopez Island Pharmacy Patient Notification Options
Use these options to tell us who is involved in your care, so that we may provide them with the information they need to assist you. We will act upon the information you provide on this form unless your inform us that it has changed. This form does not apply in the hospital setting
I would prefer to get Rx Pick Up Notifications via:
Automated Phone Call
Text Message
Email
You can leave messages at my home or on my cell phone regarding my pet's health
Yes
No
You may E-Mail me a recap of my pet's appointment and care plan
Yes
No
You may speak to family members or friends regarding my pet's health care
Yes
No
Back
Next
The individuals listed below are involved in the ongoing care of my pet. Lopez Island Pharmacists and staff may provide them with limited information about my pet's condition and care as needed to assist me.
Name #1
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Husband
Wife
Son/Daughter
Friend
Name #2
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Husband
Wife
Son/Daughter
Friend
Name #3
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Husband
Wife
Son/Daughter
Friend
Other Information
I am satisfied with the explanation regarding this form that I request and received
Person Completing this form
*
First Name
Last Name
Todays Date
*
-
Month
-
Day
Year
Date
Relationship
Owner
Friend of Owner
Submit
Should be Empty: