Client Intake Form

We look forward to your scheduled visit with us. Help us get to know you and your pet(s)
and fill out the form below prior to your visit. Thank you.

About your Scheduled Appointment

* Indicates required field

Pet Name *

Owner Name *

First

Last

Phone Number to reach you in your Car *

Why is your Pet coming to see us? *

Car Color, Make and Model *

If coming for a problem, when did this problem first appear? *

Anything you would like us to check or discuss other than the primary reason you described above? *

List your pet's current diet *

List all medications your pet is currently on (type of medication, frequency) *

List any medication you need to Pick up or Refill during this visit (medications, food, and desired quantity) *

Client Information/Authorization

So that we can best serve you, we ask that everyone provide the information below on an annual basis to keep our records up to date.

Today's Date (mm/dd/yy) *

List names of All Pets *

Primary Owner Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

DECLARATION: I, the undersigned, state that I am the owner of the above listed animal(s) and that I have sole and inclusive rights for their veterinary care. (fill out your full name) *

Primary Phone Number *

Select Primary Phone Type *

Best times to reach you at this number *

Secondary Phone Number *

Select Secondary Phone Type *

Additional Phone Numbers (number, type) *

Email *

Emergency Contact Information
In case of emergency, the emergency contact has permission to authorize medical treatment in the absence of the primary owner. The individual(s) listed here cannot make medical decisions unless the primary owner(s) listed above cannot be contacted.

Emergency Contact Name (1) *

Emergency Contact Phone Number *

Select Phone type *

Emergency Contact Name (2) *

Emergency Contact Phone Number *

Select Phone type *

Submit

About your Scheduled Appointment

Client Information/Authorization

Hours of Operation

Somerset Hills
Veterinary Services

Need Directions?

About your Scheduled Appointment

Client Information/Authorization

​Hours of Operation

Somerset Hills​Veterinary Services

​Need Directions?

Hours of Operation

Somerset Hills
Veterinary Services

Need Directions?