Welcome to Eastgate Pet Clinic!


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*  State*  Zip Code* 

Home Phone*  Cell Phone (for emergencies)

Employer  Work Phone 

Primary E-Mail Address* 

Is there someone we can contact if we cannot reach you?

 Name  Phone 

How did you choose this office (Internet, PhoneBook, Advertisement, Referral)? 

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? Yes No
If so, please list. 

Are any of your pet’s currently covered by a Pet Health Insurance Policy? Yes No
Name of Insurance 

Professional services are to be paid for at the time they are rendered. 
For your convenience, Eastgate Pet Clinic accepts the following 
methods of payment:

Cash, Check, VISA, MasterCard, Discover Card, and American Express.

Signature* I Agree 

(Your Full Name, Please Agree to Terms.)