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 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? ________

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.



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(Your signature, please.)                                   (Date)