New Client Form

Thank you for allowing us to help you care for your kitty! We want to make this as speedy and quick of a visit for your kitty as possible so they can get back home and back to their normal activities.

In order to help us accomplish this for your kitty, please read over and answer the following questions.

Please write on form and e-mail back to us at customerservice@stlouiscatclinic.com OR print it out, fill in the answers and bring it with you to your appointment.

FOOD

Food brand:(Required)

Amount:(Required)

Dry or canned or both:(Required)

Treats or other supplements:(Required)

WATER INTAKE(Required)

LITTERBOX

Bowel movements are(Required)

Too soft

Normal

Too hard

Bowel movements are(Required)

Less Frequent

Normal

More frequent

Urination is(Required)

Less than normal

Normal

More than normal

If you have observed 1 or 3 to any of the above, please elaborate here:(Required)

Have you observed any other issues with urine/bowel movements?(Required)

Yes

No

Please elaborate here:

Environment

My cat is strictly indoor

My cat has occasional supervised outdoor access such as on a leash or on screened in porch

My cat is indoor/outdoor

My cat is strictly outdoors

Pet Owner Information

Owner's Name (Mr./Ms./Mrs./Miss)(Required)

Preferred Pronouns:

Address

Street Address City State / Province / Region ZIP / Postal Code

Contact Information

Cell(Required)

Home

Work

Email(Required)

Employer

Occupation

Driver’s License #

Secondary Owner:

Owner's Name (Mr./Ms./Mrs./Miss)

Preferred Pronouns:

Cell

Home

Work

Employer

Occupation

Driver’s License #

Pet Information

Pet's Name

Gender

Spayed/Neutered?

Birthday/Age

Breed

Color

Microchip?

Previous major medical/surgical problems & dates:

In order to serve you better, please circle the letter that best describes your situation:

Is Your cat a Member of the Family or Just a Pet?

A. My cat is a member of my family

B. I feel my cat is just a pet

Do You Want Details or a Summary of Any Problems or Treatments?

A. I desire detailed explanations

B. I need only a summary of the problems & treatments

Is Your Cat Stay Indoors, Outdoors, or Both?

A. My cat stays indoors only

B. My cat stays outdoors only

C. My cat is outdoors and indoors

If you have used a veterinary clinic before and were not satisfied, please provide a brief description so we can work to avoid the same problems:

Reason for today's visit:

How did you hear about our clinic?

Patient Records

Document Upload

Max. file size: 15 MB.

If available, please upload previous veterinary records for your pet here.

During The Visit

MAY WE HAVE PERMISSION TO USE PHOTOS OF YOU AND/OR YOUR CAT ON SOCIAL MEDIA? I hereby give St. Louis Cat Clinic, Inc. permission to take photographs of me and my pet for the purpose of posting on St. Louis Cat Clinic, Inc. Facebook and/or Clinic Website. I hereby release and discharge St. Louis Cat Clinic, Inc. from any and all claims arising out of use of the photos. I am above the age of 18. I have read the foregoing statement and fully understand its contents.

Social Media Acknowlegment Signature

Date

PAYMENT IS EXPECTED UPON COMPLETION OF SERVICES For your convenience, we accept Cash, Check, Credit Card, and Care Credit I agree to pay any additional charges related to the cost of collection (including, but not limited to, collection agency fees, reasonable attorney fees, and court costs) in the event I would fail to pay my bill.

Payment Responsibility Signature(Required)

Date(Required)

Please write the best contact phone number to reach you at during the visit:

If you choose a curbside appointment, we will be calling you several times during the visit, possibly from a blocked/ private number. Please answer this call as it will save you and your kitty time! We will call after the physical exam, go over any additional questions we may have, and discuss our recommendations. We will also call you to check out, which will be done with a credit card number over the phone.
Please wait here in the parking lot during the visit, unless told specifically by a member of the staff that you are free to leave.

Thank you for helping us to make this a quick and happy visit for your feline friend!

We require 24 hours notice for cancellations. That way have that time available to help another sick kitty. Please call to cancel. 314-832-2287

CAPTCHA

For New Patients Only

FOOD

LITTERBOX

Behaviors

DECLAWED

MOBILITY

Pet Owner Information

Contact Information

Secondary Owner:

Pet Information

In order to serve you better, please circle the letter that best describes your situation:

Patient Records

During The Visit

We require 24 hours notice for cancellations. That way have that time available to help another sick kitty. Please call to cancel. 314-832-2287

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