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New Client Check in Form

Please have this form completed before your pets upcoming appointment. The information provided will help the veterinarian address all your concerns regarding your pet’s health. On the day of your appointment please call or text (480-279-2831) to check in. Our front desk team will provide you with additional information once we receive your completed form. Please have your pet on a leash or in a carrier before coming into the hospital. If your pet does not do well with other animals or requires additional accommodations, please inform one of our Client Care Specialists before your appointment. Appointment: Please arrive 10mins before your appointment time If your pet is scheduled for a routine annual exam, we recommend yearly blood work and viral screening, fecal checked twice yearly and vaccines due updated. If your pet is coming in for their annual physical exam, please bring in a fresh stool sample to the appointment. Drop off Appointment: Please provide best contact number. Our front desk team will be contacting you to provide you with additional information. Additional Information: Please download our app before your appointment to start earning Loyalty Paws! If you are interested in signing up pet on a wellness plan please let us know so we can provide you with information. We are your Compassionate Partner for the BEST health of your pet!!

Name
First Last
Are you the primary pet owner?
- Yes
- No
If you are not the owner what is your relationship to the primary pet owner?
How may we address you?
- First Name
- Dr.
- Miss
- Ms.
- Mrs.
- Mr.
Pronouns
- She/Her/Hers
- He/Him/His
- They/Them/Theirs
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Primary Phone
Secondary Phone
Secondary Owner Name
First Last
If Applicable
Relationship to Primary Owner
Secondary Owner Email
Secondary Owner Phone
Previous Veterinarian Information
Name of previous Veterinarian/Veterinary Hospital?
Phone
Do you authorize us to contact your previous Veterinarian to obtain your pets previous medical history and vaccination status? Please note that we only collect previous records so that your pet is always kept up to date on his/her Wellness Care and to keep your pets health our top priority.
- Yes
- No
Please provide as much information you can about your pet or pets:
Please list all pet(s) in your household
Please include Name, Species, Age (if known)
Pet insurance provider?
If applicable
Please list all pet(s) in your household covered by health insurance
List any other veterinary provider who have treated your pets in the last 12 months.
Do you give Seville Veterinary Hospital permission to contact the veterinary practice above for your pet (s) records?
- Yes
- No
- I will bring the records with me for you to copy.
Do you give SVH consent to release your pet (s) medical records and vaccination records to the following:
Hold CTRL key to select multiple
Please list any party that you do not want SVH to release records to:
How would you prefer to receive bloodwork and or any other test results for your pet(s)?
- Phone
- Text
- Email
The following individuals have your permission to make medical decisions pertaining to my pet(s)health. The individual listed are also authorized to receive my pet(s) medical record.
Please list name, relationship to you, and phone number.
Photography Notice
- Yes, I will allow Seville Veterinary Hospital to use my pet’s image and name on their social media.
- No, I will not allow Seville Veterinary Hospital to use my pet’s image beyond their private medical history.
Seville Veterinary Hospital sometimes shares patient’s cute photos on social media.
Authorization and Acknowledgement:*
I agree to the below policy.
Seville Veterinary Hospital does not provide 24-hour care. Seville Veterinary Hospital provides owner(s) with Best Medicine options to make informed decisions regarding their pet(s) health. I hereby authorize Seville Veterinary to examine, prescribe and treat my pet(s). I understand depending on the medication prescribed I have the option to use a pharmacy other than SVH for my pet(s) medications. I understand Seville Veterinary Hospital uses video and audio monitoring/surveillance for the safety of clients, patients, employees, and staff training.
Payment Policy*
I agree to the below policy.
I understand payment is due at the time of service. If your pet is need of specialty surgery, procedure, or treatment a deposit will be required.
Payment options available; Cash, Visa, Mastercard, American Express, Discover, and Care Credit.
I verify I have read and understand all notices listed above. I also verify that the information I have entered is true and correct, and this box acts as my signature of acknowledgement.
Today's Date
Date Format: MM slash DD slash YYYY
PLEASE FILL OUT THE INFORMATION BELOW FOR THE PET THAT HAS THE APPOITMNET. Provide as much information you can about the patient.
First Name Last Name
Date Of Birth
Date Format: MM slash DD slash YYYY

Approx
Sex
- Male
- Female
Spayed or Neutered
- Spayed
- Neutered
- Intact
Species
- Dog
- Cat
Breed
Color
Microchip Number (If you have one)
When was your pet last vaccinated
Does your pet have any known allergies?
Does this pet have health insurance?
- Yes
- No
If yes, please list here
Briefly describe the reason your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.
For how long has your pet been experiencing the problem described above?
Has your pet had any coughing?
- Yes
- No
If yes, for how long? Please provide more details.
Has your pet had any sneezing?
- Yes
- No
If yes, for how long? Please provide more details.
Has your pet had any nasal discharge?
- Yes
- No
If yes, for how long? Please provide more details.
Has your pet had any vomiting?
- Yes
- No
If yes, for how long? Please provide more details.
Has your pet had any diarrhea?
- Yes
- No
If yes, for how long? Please provide more details.
Does your pet’s stool look normal in color?
- Yes
- No
Has your pet been drinking more?
- Yes
- No
Has your pet been urinating more?
- Yes
- No
Have you seen your pet's urine?
- Yes
- No
If yes, what was the color and amount?
Has your pet's appetite changed?
- Yes
- No
If yes, for how long? Please provide more details.
When was the last time you saw a bowel movement and what did it look like?
What is the name of the food you feed your pet? Is it canned, dry or both? Specifically, what is the volume of food and treats you are feeding per day?
Is your pet lethargic (not active)?
- Yes
- No
If yes, for how long? Please provide more details.
Is your pet here because it is limping?
- Yes
- No
Please list all medications and supplements/vitamins (name, strength, and amount) your pet is on and when they were last given:
Any additional information that you feel would be helpful in treating your pet. We will do our best to have your pet seen and communicate a plan as quickly as possible
THANK YOU FOR COMPLEATING THE NEW CLIENT AND PATCIENT INFORMATION!
Consent
I have filled out the above form to the best of my knowledge and agree to all required terms.*
Please type your name to act as a digital signature.
Today's Date
Date Format: MM slash DD slash YYYY

Ready To Make An Appointment? Book Now!

Contact Us

6348 S. Higley Rd., Suite 109 Gilbert, AZ 85298

Phone: 480-279-2831 Fax: 480-279-6501

Hours of Operation

Monday 7:30 am – 6:00 pm Tuesday 7:30 am – 7:00 pm Wednesday 7:30 am – 6:00 pm Thursday 7:30 am – 7:00 pm Friday 7:30 am – 6:00 pm Saturday 8:00 am – 2:00 pm Sunday Closed

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New Client Check in Form

Previous Veterinarian Information

Please provide as much information you can about your pet or pets:

Contact Us

Hours of Operation