Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Secondary Owner

First Name

Last Name

Secondary Owner's Phone

(###)

###

####

Pet's Name *

Pet's Age or Date of Birth *

Species * Canine Feline Other - write in species below

Sex * Female Male

Neutered/Spayed * Yes No Unknown

Breed *

Coat Color *

Do you have pet insurance? * Yes No

Name of Primary Care Veterinarian(s) or Hospital(s) *

Medical History

What are your pet's symptoms? *

When did you first notice these symptoms? *

Current Medications and Supplements *

Please include full medication name, dose, and frequency given. Include any flea/tick/heartworm preventatives (e.g. Frontline, Heartgard)

Is your pet up to date on their Rabies vaccine? * Yes No

Any known allergies? * No Yes - please list all allergies below

Current Diet/Foods *

Include brand name, flavor, type, amount fed per meal, frequency of meals, and any additional treats

Treatment Authorization and Financial Policy

I hereby authorize the veterinarians and staff to examine, prescribe for, and/or treat the above-described pet. I understand that I can terminate treatment at any time. If I have been referred to IMVC by another veterinarian, I understand that they will require a summary of the care and treatment provided by IMVC in order to ensure that my pet’s care can be continued without interruption. I also understand that IMVC considered my identification of a primary/referring veterinarian to be my authorization to release records and information to the veterinarian.

I assume responsibility for all charges incurred in the care of this pet. I also understand that payment in full is due at the time of services. We offer the following payment and credit options: Visa, Mastercard, Discover, American Express, Apple Pay, Android Pay, and cash.

I have read and understand the above treatment and financial policy and agree I am over 18 years of age. *

Owner's (authorized party) typed name indicates acknowledgement of treatment authorization and financial policy:

COVID-19 Policy

Health and wellness are central goals of Integrative Mobile Veterinary Care. With that in mind, we are proactive in minimizing risk of disease transmission to protect ourselves, our clients, and our small business. Dr. Wilson is fully vaccinated against COVID, but for the safety of our clients and their families will continue to wear a mask during visits, and requests that anyone present during the visit be masked as well. Social distancing is required during visits. If anyone in the home is ill with respiratory signs (coughing, sneezing) or recently tested positive for COVID please let us know prior to your appointment.

I have read and understand the above COVID-19 protocol and agree. *

Owner's (authorized party) typed name indicates acknowledgement of COVID-19 protocol:

Optional Media Release Form

I hereby grant permission for Integrative Mobile Veterinary Care to use photographs and/or videos of my pet taken during appointments in publications, news releases, social media, and in other communications with all identifying information removed.

Owner's (authorized party) typed name indicates acceptance of media release form: