New Patient Form Please fill out this form for each of your individual pets. New Patient FormPet's Name *Human's Name *Email *Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryHome Phone *Cell Phone *OK to text? YesNoHow did you first learn of Handle With Care Home Veterinary Service? Advertising?Referral?OtherPlease specify Pet Type DogCatOtherPlease specify Pet's Birthdate Pet's Gender MaleFemaleAgreement As the owner or authorized agent of the pet described above, I hereby authorize Dr. Kimberly Curtis and staff of Handle With Care Home Veterinary Service, PC to perform the services I request, and all other procedures, diagnostics, treatments, and/or administration of prescription medications and over the counter medications/supplements (both label and off-label) within accepted veterinary guidelines as deemed advisable and/or necessary for my pet(s). Dr. Curtis and staff will take every reasonable action to ensure the success of my pet’s treatment/procedure, but the possibility of death as a severe complication of any procedure does exist. There is no guarantee, nor can one be made as to the results or cure of any therapy. I agree to pay, in full, for any and all services rendered at the point of service. I understand and agree to the terms of Handle With Care Home Vet’s cancellation policy.E-Signature *By checking "yes" you affix your e-signature to the above statement.YesNoPet's Medical HistoryInstructions What follows are guidelines for creating a summary of your pet’s medical history. While I will also want to review relevant medical records from veterinary providers, I am as much interested in YOUR viewpoint.Health Summary Please provide a detailed summary of your concerns regarding your pet’s health:Specific Concerns Please provide a list of past medical concerns (illnesses, surgeries, etc), including approximate dates of occurrence. If certain problems recur frequently, please indicate that as well:At what age did you acquire (adopt) your pet? Diet Please provide specifics about your pet(s) usual diet (past and present):Medicines and Supplements Please provide a current list of medications and supplements/vitamins. Indicate dosage and frequency as well. Helpful to have medications and supplements available for review during the appointment:Vaccination History Please provide vaccination history for last 5 years:Rabies Distemper Combo Lyme Bordatella FVRCP FELV Titer results Other File Upload Please have your veterinary providers fax (773-305-8296) or email (curtisvet1@gmail.com) any relevant medical records from at least the last 12 months, or upload here. I may request additional medical records during our visit. VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
