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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number Home:Cell Phone Number:Other Phone Number:Email: Tell us about your pet!Patients Name: Breed: Year of Birth or age: MM slash DD slash YYYY Gender: Male Female Spayed/ 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: normal reduced increased Energy is highest in the: morning afternoon night consistent Attitude/mood is best in the: morning afternoon evening night consistent 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: Happy Content Restless Crabby Depressed 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: morning afternoon evening night consistent 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: MM slash DD slash YYYY 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!
