New Patient Information Form New Patient Information Form Client InformationOwner’s Name* First Last Secondary Owner First Last Primary Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us?Patient InformationPet Name* Gender* Spayed/Neutered* Yes No Breed* Color* DOB/Age* Has your pet had any previous adverse reactions to medications or vaccinations?* Yes No If yes, please explain*At Macungie Animal Hospital, we want your pet to be as comfortable with his/her visit as possible. In order to anticipate any fear or anxiety issues, we’d appreciate your answers to the following questions:Does your pet suffer from increased stress or anxiety during nail trims, around other dogs, when his/her feet are touched, or for any other reason(s)?* Yes No If yes, please explain*Has your pet ever bitten anyone:* Yes No No If yes, please explain the circumstances:*Previous Veterinary Clinic(s) if applicablePlease list past medical and/or surgery historyCurrent Medications and/or supplementsAll pets seen at Macungie Animal Hospital must be accompanied by an individual who is 18 years or older.
