Emergency: (231) 922-0911
Join Our Team
Icon List Item

Emergency: (231) 922-0911
Join Our Team


Home
About
Services
Resources
Online Forms
Online Store
- Online Pharmacy
- Hill’s To Home
Contact
Companion Care Plans
Request Appointment

Home
About
Services
Resources
Online Forms
Online Store
- Online Pharmacy
- Hill’s To Home
Contact
Companion Care Plans
Request Appointment

Dog/Cat Welcome Form

Please complete this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

a dog standing in grass near water

Dog/Cat Welcome Form

"*" indicates required fields

Owner's Name*

First Last

Owner's DOB*

MM slash DD slash YYYY

DL#*

Today's Date*

MM slash DD slash YYYY

Spouse Name

Street Address*

Address Line 1 Address Line 2 City State ZIP Code

Home Phone*

Cell Phone

Email Address*

Spouse Phone

Work Phone

Employer

Emergency Contact Name*

Emergency Phone*

How did you learn of our hospital?*

Internet

Facebook

Website

Other Veterinarian

Client Referral

Sign/Drive By

Phone Book

Other

Who referred you?

Number of Pets

Dogs

Cats

Other

Pet Health History

Pet Name*

Dog, Cat, Other*

Breed*

Color*

Please check (√) any symptoms or problems that you have noticed about your pet.*

Behavior Problems

Lack of Appetite

Sneezing

Bleeding Gums

Limping

Thirst Increase

Urination Changes

Breathing Problems

Loss of Balance

Vomiting

Coughing

Scooting

Weakness

Diarrhea

Scratching

Eye Problems

Seems Depressed

Gagging

Shaking Head

Other

None

Sex*

Male

Neutered Male

Female

Spayed Female

Date of Birth*

MM slash DD slash YYYY

Vaccination History*

Medications*

Diet*

Do you have a second pet?*

Yes

No

Pet Name*

Dog, Cat, Other*

Breed*

Color*

Please check (√) any symptoms or problems that you have noticed about your pet.*

Behavior Problems

Lack of Appetite

Sneezing

Bleeding Gums

Limping

Thirst Increase

Urination Changes

Breathing Problems

Loss of Balance

Vomiting

Coughing

Scooting

Weakness

Diarrhea

Scratching

Eye Problems

Seems Depressed

Gagging

Shaking Head

Other

None

Sex*

Male

Neutered Male

Female

Spayed Female

Date of Birth*

MM slash DD slash YYYY

Vaccination History*

Medications*

Diet*

Do you have a third pet?*

Yes

No

Pet Name*

Dog, Cat, Other*

Breed*

Color*

Please check (√) any symptoms or problems that you have noticed about your pet.*

Behavior Problems

Lack of Appetite

Sneezing

Bleeding Gums

Limping

Thirst Increase

Urination Changes

Breathing Problems

Loss of Balance

Vomiting

Coughing

Scooting

Weakness

Diarrhea

Scratching

Eye Problems

Seems Depressed

Gagging

Shaking Head

Other

None

Sex*

Male

Neutered Male

Female

Spayed Female

Date of Birth*

MM slash DD slash YYYY

Vaccination History*

Medications*

Diet*

Previous veterinarian?

Other information we need to know?

Authorization*

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal(s). I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. I also authorize the hospital to use photos and/or other likeness of myself and/or my pet(s) for their medical record or other purposes. Must be 18 or older to authorize.

Signature of Owner*

Date*

MM slash DD slash YYYY

Method of Payment

Cash

Check

MasterCard

Visa

CareCredit

Discover

American Express

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Book an Appointment!

Connect with us! Companion Animal Hospital proudly serves the communities of Williamsburg, Acme, Kingsley, Lake Ann, Interlochen, Elk Rapids, and surrounding areas. Click the button below to schedule an appointment now, or download our app to keep track of your pet’s health.

Request Appointment Download App

petdesk app view

Have Questions?

Get in touch. Complete our form, and a member of our team will be in touch with you shortly.



Address

1885 Chartwell Drive
Traverse City, MI 49696



Contact Information

Phone: (231) 935-1511
Email: reception@cahtc.com



Hour of Operation

Mon & Thurs: 7:30 am – 5:30 pm*
Fri: 7:30 am – 5:00 pm*
Sat & Sun: Closed
* Phones turn off a half-hour prior to close

Name *

First

Last

Email *

Phone

How can we help you? *

Phone

payment option icon

© 2024 Companion Animal Hospital | Powered by WhiskerCloud | Privacy Policy | Accessibility Statement