New Client Inquiry Form

Please complete this new client inquiry form to help us get to know you and your pet. It asks for basic contact information, details about your animal(s), and the services you’re interested in.If you do not receive an acknowledgement email, your form has not been submitted.Once submitted, the HSNEI medical team will reach out to you within 5 days with next steps and scheduling information. Please email wellness@hsnei.org with any questions!

Client Information
First Name *
Last Name *
Street Address *
City *
State *
Zip Code *
County *
Primary Phone Number *
Secondary Phone Number
Primary Email Address *
Confirm email
Secondary Email Address
Preferred Contact Method *	Email Text Phone Call
Co-Owner/Secondary Owner Name
Co-Owner/Secondary Owner Phone Number
Co-Owner/Secondary Owner Email Address
How did you hear about HSNEI's Wellness Services? *	Social Media HSNEI Website Signage Word of Mouth Newspaper Television Broadcast Radio Broadcast
Animal Information
Pet's Name *
Species *
Primary Breed *
Secondary Breed
Color *
Pet's Date of Birth * Please provide an estimated date of birth for your pet.
Sex *	Male Female
Sterilization Status *	Spayed/Neutered Not Spayed/Neutered
Approximate Weight *
Microchip Number
Name of Previous Vet Clinic * Write "N/A" if pet has not been seen by a veterinarian or clinic previously. This information will only be used to facilitate a transfer of records.
Date of Last Visit at Previous Vet Clinic Provide an approximate date if unsure. Leave field blank if pet has not been seen by a veterinarian or clinic previously.
Owner Name on Previous Records Please provide the owner name attached to any previous records. This information will only be used to facilitate the transfer of medical records.
If the pet is a cat, what environment do they live in? Only answer this question if your pet is a cat. If you are filling out the form for a dog, please leave this field blank.	Indoor Only Primarily Indoors with Outdoor Exposure Equal Time Inside and Outside Primarily Outdoors Outdoor Only
If the pet is a dog, what outdoor activities does the dog participate in? Only select activities if the pet is a dog. If you are filling out the form for a cat, please leave this field blank.	Hiking Hunting Dog Parks Pet Boarding Swimming
If the pet is a dog, is the dog housed indoors, outdoors, or both? Only answer this question if the pet is a dog. If you are filling out the form for a cat, please leave this field blank.	Primarily Indoors Both Indoors & Outdoors Primarily Outdoors
Which of the following does the pet have regular contact with? *	Cat(s) Dog(s) Children Livestock Other Indoor Pets None of the Above
Health History and Current Symptoms
What services are you interested in for this pet? *	Spay/Neuter Sick Appointment Vaccination Wellness/Preventative Other
If you are requesting a sick appointment, what symptoms is the pet currently experiencing? Include how long each symptom has been present. Provide as much information as possible. Leave blank if not requesting a sick appointment at this time.
How is the pet's eating and drinking? *	Normal Abnormal
If you selected "Abnormal" in the previous question, what is abnormal about the pet's eating and/or drinking?
Are the pet's urination and defecation habits normal? *	Normal Abnormal
If you selected "Abnormal" in the previous question, how has the pet's urination and/or defecation been abnormal?
Medications and Supplements * Include the name, dosage, and frequency of each medication and/or supplement given to the pet. If the pet does not take any medications or supplements, please write "None."
Known Allergies * Include information on each allergen and corresponding reaction. If no known allergies, write "None."
Pet's Vaccination Status *	Current Past Due Unsure
Has the pet ever had a reaction to a vaccine? If yes, please note the vaccine administered and what the reaction was. * If the pet has not had a vaccine reaction, write "None."
Preventative Care * Please list any flea/tick/heartworm preventatives being used and the date last given. If the pet has not been given preventatives, please write "None."
What brand, type, and amount of food does the pet eat each day? *
Does the pet have any behavioral concerns that may impact their visit? Please include any pertinent information about interactions with dogs, cats, new people, car rides, places they don't like to be touched, etc.
Is there anything else we should know to make your pet's experience at HSNEI as positive and comfortable as possible?