New Client Form

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Full Name* This field is required.
First Name
Last Name
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Date of Appointment* This field is required.Please make sure your appointment is confirmed with our clinic before completing this section!
Date
Month
Day
Year
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Hour
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Minutes
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AM
PM
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We are currently offering our clients the option of coming inside for their exam or remaining curbside. If you do opt to come inside, please keep in mind that appropriately worn face masks are required regardless of vaccine status.
Curbside
In-Clinic
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Due to the current COVID-19 situation, as of December 2nd, 2021 we are reinstating our curbside protocol for all appointments. Please select "I understand" from the dropdown menu as acknowledgement of this protocol. If you have any questions, or need to reschedule your appointment, please call 304-292-6933. As of this time, we are unsure when this protocol will be lifted.
I understand
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Phone Number* This field is required.Primary contact phone number for client/clinic communication.
ex: 304-555-5555
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Phone Number* This field is required.
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
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
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
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
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Email* This field is required.
example@example.com
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Spouse/Co-Owner
First Name
Last Name
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Spouse/Co-Owner Phone NumberSecondary phone number for account
ex: 304-555-5555
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Spouse/Co-Owner Phone Number
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Pet's Name* This field is required.
Pet #1
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Pet Species* This field is required.
Cat
Dog
Please Choose One
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Pet Breed* This field is required.
i.e. German Shepherd, Husky, DSH (shorthaired cat), DLH (longhaired cat), Persian, etc.
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Color/Markings* This field is required.
i.e. Black/White, Brindle, Tri-Color, Tabby, etc.
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Birth Date* This field is required.Estimated Date Is Accepted
Month
Day
Year
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Sex/Altered* This field is required.
Male
Male, Neutered
Female
Female, Spayed
Please Choose One
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Purpose of Visit* This field is required.
Establish Care
Establish Care
New Puppy or Kitten
Second Opinion
Transfer/Sick Visit
Please Choose One
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Do you have your pet's medical records/vaccination history with you today?* This field is required.
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Is your pet currently on flea, tick, and/or heartworm and intestinal parasite prevention?* This field is required.
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Is your pet currently on any other medications or supplements?* This field is required.
Cosequin, Dasuquin, Glycoflex, or another joint supplement
Forti-Flora, Mycequin, or other Probiotics
Psyllium husk powder, Metamucil, or another fiber supplement
Composure, Adaptil/Feliway, CBD oil, or other calming aids
None
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Is your pet allergic to any medications, vaccines, or foods?* This field is required.
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If yes, please list below
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Please note: We take pride in the quality of service and medical care you trust us with providing you and your pet. In an effort to maintain these standards, and to keep your costs down, we do not bill for services rendered. Payment is due at the time of service.

We accept cash, check, Care Credit, Scratchpay, VISA, MasterCard, Discover, and American Express.

By signing this form, you acknowledge that the information provided is accurate to the best of your knowledge, and that you agree to pay for professional services and medications as they are rendered. You may ask us for a copy of our financial policy or for an estimate of expected services at any time.
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Please arrive to your appointment at your scheduled time. Due to our current scheduling restrictions, if you are more than 10 minutes late we will need to reschedule your appointment.

To ensure we are able to provide accurate and prompt care for your pet, please make sure we receive your pet's previous veterinary/medical records at least 24 hours before your appointment so our doctor can review them. If we do not receive records before your appointment time, we do reserve the right to reschedule your appointment. (This does not apply if your pet has never been seen by a veterinarian or has no medical history.)

Failure to reschedule or cancel your appointment at least 48 hours before your scheduled appointment time will result in the forfeiture of your deposit, and a new deposit will be required before you can schedule a new appointment.
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I hereby certify that the information on this form is true and accurate. I acknowledge the payment and scheduling policies set forth in the two previous pages.* This field is required.
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Today's Date* This field is required.
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The following questions are part of our ongoing mission to provide a Fear Free experience for all of our patients. Please answer as accurately as you can so that we can be prepared to provide the best experience for you and your pet.

Please visit Fear Free Pets to learn about Fear Free protocol and what that means for you and your pet. If you have any questions, please call us at 304-292-6933, email us at reception@hillcrestveterinaryclinic.com , or send a chat via our Hillcrest VC App (Android/iPhone). We're always happy to help!
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Does your pet mind being around other animals?* This field is required.This question is part of our Fear Free Protocol behavior survey. Please answer as accurately as possible. Thank you!
YESNO
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Has your pet been prescribed anxiety or sedative medication in the past?* This field is required.This question is part of our Fear Free Protocol behavior survey. Please answer as accurately as possible. Thank you!
YESNO
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Has your pet been prescribed anxiety or sedative medication in the past?* This field is required.This question is part of our Fear Free Protocol behavior survey. Please answer as accurately as possible. Thank you!
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When your pet goes to the vet, they are...* This field is required.This question is part of our Fear Free Protocol behavior survey. Please answer as accurately as possible. Thank you!
Eager/Excited
Calm/Happy
Subdued/Reluctant
Fearful
Aggressive
Not sure- we haven't been to the vet before!
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What kinds of treats does your pet like?* This field is required.This question is part of our Fear Free Protocol behavior survey. Please answer as accurately as possible. Thank you!
Chicken Jerky (Canine)
Peanut Butter (Canine)
Liver Flavored 'Kong' Paste (Canine)
Spray Cheese (Canine)
Tempations (Feline)
Churu Paste (Feline)
I'll bring my own 😊
They won't eat away from home! 🤷🏽
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Does your pet have any other preferences or issues we should be aware of? ie prefers men or women, vision/hearing impaired, leash reactive, etc. If none, please type N/A.* This field is required.This question is part of our Fear Free Protocol behavior survey. Please answer as accurately as possible. Thank you!
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