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New Patient Intake Form

Start Your Pet’s Journey to Better Health!

New Patient Intake Form

Please complete and submit our intake form. This information is required for all new pet/patients.

"*" indicates required fields

Step 1 of 2

50%

Contact Information

Owner Name*

Co-Owner Name

Address*

Street Address Address Line 2 City State ZIP Code

Owner Email*

Co-Owner Email

Cell Phone*

Work Phone

Home Phone

Co-Owner Cell Phone

Co-Owner Work Phone

Co-Owner Home Phone

Name of Previous Clinic*

Previous Clinic Phone*

Owner's Place of Employment

Co-Owner's Place of Employment

How did you hear about us?

Recommended

Internet Search

Social Media

How would you like to receive vaccine reminders?*

Email

Paper

How would you like to receive appointment reminders?*

Email

Text

Phone Call

Consent Agreement

Terms*

I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.

I /We Agree

Date*

MM slash DD slash YYYY

Pet Information

Number of pets:*

One

Two

Three

Four

Pet #1

Select One*

Dog

Cat

Pet #1 Name*

Breed*

Date of Birth*

MM slash DD slash YYYY

Microchip #

Pet Sex*

Male

Female

Spayed or Neutered?*

Yes

No

Pet #1 Vaccination Records

Possible Dog Vaccines -Rabies -Distemper/Parvo -Lymes -Bordatella -Heartworm Test Possible Cat Vaccines -Rabies -Distemper -Feline Leukemia

Additional Information

Pet #2

Select One*

Dog

Cat

Pet #2 Name*

First

Pet Breed*

Date of Birth*

MM slash DD slash YYYY

Microchip #

Pet Sex*

Male

Female

Spayed or Neutered?*

Yes

No

Pet Color

Pet #2 Vaccination Records

Possible Dog Vaccines -Rabies -Distemper/Parvo -Lymes -Bordatella -Heartworm Test Possible Cat Vaccines -Rabies -Distemper -Feline Leukemia

Additional Information

Pet #3

Select One*

Dog

Cat

Pet #3 Name*

First

Pet Breed*

Date of Birth*

MM slash DD slash YYYY

Microchip #

Pet Sex*

Male

Female

Spayed or Neutered?*

Yes

No

Pet Color

Pet #3 Vaccination Records

Possible Dog Vaccines -Rabies -Distemper/Parvo -Lymes -Bordatella -Heartworm Test Possible Cat Vaccines -Rabies -Distemper -Feline Leukemia

Additional Information

Pet #4

Select One*

Dog

Cat

Pet #4 Name*

First

Pet Breed*

Date of Birth*

MM slash DD slash YYYY

Microchip #

Pet Sex*

Male

Female

Spayed or Neutered?*

Yes

No

Pet Color

Pet #4 Vaccination Records

Possible Dog Vaccines -Rabies -Distemper/Parvo -Lymes -Bordatella -Heartworm Test Possible Cat Vaccines -Rabies -Distemper -Feline Leukemia

Additional Information

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At Kenyon Veterinary Clinic, our patients are our purpose. We are dedicated to providing compassionate, high-quality veterinary care for pets in Kenyon, MN, and surrounding communities.

Get In Touch!

109 Forest St. | Kenyon, MN 55946

(507) 789-6118

(507) 789-6119

Email Us

Monday to Friday, 7:30 AM – 5 PM

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