Client Registration and Patient Questionnaire Form 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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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:MaleFemaleSpayed/ Neutered:YesNoColor:Microchipped:YesNoInsured:YesNoContact Number for Insurance:Previous veterinary health care providers:May we contact them for record requests:YesNoPatients Current Medications:Patients Current Diet:Brief description of patients current living environment:Reason for appointment:Energy and Well-Being:Energy level in general is:normalreducedincreasedEnergy is highest in the:morningafternoonnightconsistentAttitude/mood is best in the:morningafternooneveningnightconsistentMy 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:HappyContentRestlessCrabbyDepressedMy pet prefers:to be coolto be warmdoes not have a preferenceSleep is:normaldecreasedincreasedrestless at nightDreams?nonevocalizationrunningMobility:Mobility level is:normalreducedincreasedMobility is best in the:morningafternooneveningnightconsistentMy pet has a specific area that is weak or lame:yesnoIf “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:YesNoIn 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. Be sure to "like" us on Facebook or follow us on Instagram!