Client Registration and Patient Questionnaire Form in Scotts Valley CA

Thank you for choosing Nautilus Pet Rehabilitation. We are so happy your here!

We are dedicated to providing your pets with high quality compassionate medicine. We look forward to becoming an important part of keeping your pet happy and healthy.

Tell us about you!

Owner’s Name:

Spouse, if Applicable:

Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number Home:

Cell Phone Number:

Other Phone Number:

Email:

Tell us about your pet!

Patients Name:

Breed:

Year of Birth or age:

Gender:

Male
Female

Spayed/ Neutered:

Color:

Microchipped:

Insured:

Contact Number for Insurance:

Previous veterinary health care providers:

May we contact them for record requests:

Patients Current Medications:

Patients Current Diet:

Brief description of patients current living environment:

Reason for appointment:

Energy and Well-Being:

Energy level in general is:

normal
reduced
increased

Energy is highest in the:

morning
afternoon
night
consistent

Attitude/mood is best in the:

My pet is:

easily excited (eg. papillon)
goal driven (eg. border collie)
dominant and competitive (eg. jack russell)
observant and solitary (eg. St. Bernard )
friendly and obedient (eg. Labrador)

My pet is:

My pet prefers:

to be cool
to be warm
does not have a preference

Sleep is:

normal
decreased
increased
restless at night

Dreams?

none
vocalization
running

Mobility:

Mobility level is:

normal
reduced
increased

Mobility is best in the:

My pet has a specific area that is weak or lame:

yes
no

If “Yes,” please select all that apply:

Front right leg
Front left leg
Back right leg
Back left leg

My preferred method of communication:

Text
Email
Phone

How did you hear about us?

Yelp
Sign
Referral
Facebook
Instagram
Google Search
Other

I understand that payament is due in full at the time of service. We will gladly prepare a written treatment plan before services are rendered upon request.

I consent to sharing my pet on social media and marketing materials:

Yes
No

In the case of a medical emergency, if I cannot be reached, I herby give the below person(s) permission to authorize Nautilus Pet Rehabilitation and/or Coast Veterinary to provide any medical treatment deemed necessary for my pet and permission for the doctor to treat to their best clinical judgment. I will be responsible for charges incurred in that treatment.

Name:

Phone Number:

Name:

Phone Number:

Signature:

Date:

Thanks for entrusting us with your four legged friends care. We consider it an honor and strive to provide the highest quality care available.
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