Please take a few minutes to complete this questionnaire to help us serve you better. Thank you.
Owner’s name: (Mr. / Mrs. / Miss / Ms. / Dr. / Rev.)
Co-owner’s name: (Mr. / Mrs. / Miss / Ms. / Dr. / Rev.)
Home address P.O. Box
City and State Zip Code
Home Phone Cell Phone (for emergencies)
Employer Work Phone
Is there someone we can contact if we cannot reach you?
Name Phone
How did you choose this office?
Who may we thank for referring you?
What foods do your pets eat at home?
Have any of the pets in your home had any severe illness in the past, such as Distemper, Parvo-virus, or Feline Infectious Peritonitis? If so, please list.
Are any of your pet’s currently covered by a Pet Health Insurance Policy? Name of Insurance
Professional services are to be paid at the time they are rendered. For your convenience, the Eastgate Pet Clinic accepts the following methods of payment:
Cash, Check, VISA, MasterCard, Discover Card, and American Express.