Forms

New Patient Form

To those of you who are new to us, we’re so glad to meet you!
Please take a moment to complete the form below with all of the appropriate information so we may get to know you and your pet better.

"*" indicates required fields

Choose an option to begin:*

New client with a new pet

Existing client with a new pet

Pet Owner/Primary Contact*

First Name Last Name

Owner's Spouse/Partner

First Name Last Name

Mailing Address*

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

Place of Employment*

Primary Phone*

Is this a mobile number?*

Yes

Secondary Phone

Is this a mobile number?

Yes

Email*

Conway Veterinary Hospital, PPLC will not share email information. This is simply a convenient way for us to share info.

Preferred Method of Contact*

Primary Phone

Secondary Phone

Your Pet's Health History

Pet's Name*

Species*

Species (Other)*

Please describe the species of your pet.

Do you plan on having your pet spayed/neutered?*

Yes

If no, do you plan on breeding your pet?*

Yes

Date of Birth*

MM slash DD slash YYYY

Breed*

Color*

Is your pet microchipped?*

Yes

Microchip #*

Would you like to have your pet microchipped?*

Yes

Do you use heartworm prevention?*

Yes

What Brand?*

How often do you administer heartworm prevention?*

Year round

Seasonally

Do you use flea and tick prevention?*

Yes

What Brand?*

How often do you administer flea and tick prevention?*

Year round

Seasonally

Has your pet ever had a dental cleaning?*

Yes

Does your pet go swimming in lakes and/or streams?*

Yes

Does your pet go hiking with you?*

Yes

What symptoms or problems have you noticed about your pet? (Check all that apply)*

Behavioral Problems

Bleeding Gums/Bad Breath

Breathing Problems

Coughing

Depression

Disorientation

Eyes Bulging or Bloodshot

Gagging

Lack of Appetite

Lameness

Loss of Balance

Scooting/Scratching

Shaking Head/Itching

Sneezing

Increased Thirst and/or Urination

Vomiting/Diarrhea

Weekness

Other…

Symptom or problem not listed*

What is the reason for your office visit?*

What brand of food do you feed your pet?*

Current medications*

Previous health conditions*

Any concerns regarding behaviors? (Check all that apply)

Excessive Barking

House Breaking

Jumping

Nipping

Overly Rambunctious

Problems Around Children

Other…

Behavioral concern not listed*

Would you like more information about any of the following? (Check all that apply)

Microchip

Dental Care

Flea/Tick/Heartworm Prevention

Vaccinations

Nutrition

Allergies

FIV Testing

Spaying/Neutering

Lyme disease

Leptospirosis

Something else…

More info on something not listed*

Terms & Policies

Terms & Conditions
I am the legal owner (or duly authorized agent for the owner) of the pet described, and I hereby authorize the veterinarians and professional staff of Conway Veterinary Hospital, PLLC to examine, prescribe for, and treat said pet. I assume responsibility for all charges incurred in the care of my pet. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

Type your name to agree and consent to these terms*

Social Media Consent
At Conway Veterinary Hospital, we appreciate all of our clients and would love to make your pet Facebook and Instagram famous! Please give us your permission to share an image and story of your pet on social media with your consent below. We promise your personal information will not be shared.

Social media consent*

I consent to Conway Veterinary Hospital, PLLC sharing my pet on future social media posts

Please do not share my pet on social media

Typing your name confirms your social media consent*

24-Hour Cancellation/No Show Policy
We understand that your time is very valuable to you, and to respect your time and that of ALL our clients, we will require 24-hour notice to cancel your appointment. We do understand that we all have busy lives and things can come up at the last minute from time to time, however, last minute cancellations and no shows will be subject to a cancellation fee that equals the value of the respective exam charge..

Typing your name means you agree and consent to our cancellation/no show policy*

Late Fee Policy
While we understand that unforeseen circumstances may cause you to be a few minutes late for your pet’s appointment, we hope you understand that delay may prevent us from providing appropriate care for your pet without creating delays for our other clients and patients.

If you are more than 5 minutes late (for your 20 minute appointment), we will likely need to reschedule your pet’s appointment. If we can arrange our schedule to absorb the delay and still provide your pet’s care, you will see a $20 late fee added to your invoice.

Typing your name means you agree and consent to our late fee policy*

Financial Policy
We know you have the best interest in mind for your pet. We strive to provide affordable services and accept several methods of payment; however, payment is due at the time of treatment. Each patient is charged with an appropriate exam fee which covers both the veterinarian examination and consultation. Additional fees are charged for services and diagnostic tests as determined by your pet’s condition. An estimate of these fees will be discussed with you and in some cases, a printed estimate will be generated prior to initiation of treatment.

We have several choices for payment of services provided. Conway Veterinary Hospital offers a no-interest payment plan pending approval through Care Credit. We accept personal checks (we DO NOT accept postdated checks), Visa, Mastercard, Discover, American Express, and debit cards. Care Credit is a payment plan established through GECredit that allows you to start treatment today and spread payments over time. You can learn more about and apply for Care Credit by clicking here. Applying for Care Credit only takes a few minutes and there is no fee to apply. If your application is declined, another form of payment listed below is required.

Payment Options:

Cash
Check
Debit Card
Visa / Mastercard / Discover/American Express
Care Credit
All Pet

I agree to pay for my pet's services in full the day of my appointment with one of these payment options*

Credit Card Processing Fees
In the event that you choose to make payments via credit card, a card processing fee of 2.5% will be applied. This fee covers the charges for processing card transactions and is not included in the standard service fees. The card processing fee will be calculated as a percentage of the total invoice amount and will be clearly indicated when a card is entered. There is no fee for using a debit card.

Credit Card Fee Acceptance*

Initial here to acknowledge and agree to the application of this fee when opting to pay by card. The specific percentage for the card processing fee can be subject to change and if so, we will communicate as early as possible.

Having an issue submitting the form?

Apologies for any inconvenience.
Here are some options:
1. Email us at info@myconwayvet.com with specifics as to what you’re experiencing.
2. Try switching to a different web browser, an incognito/private window, or if you’re on a mobile device, switch to a desktop computer or laptop.
3. Click here to download a printable version of the form that you can complete and either email to us or bring in to your next visit.

Cat Break!

Pre-Visit Form

We want to make your pet’s veterinary experience as enjoyable and as stress-free as possible. As such, it’s important for us to understand what your pet might find upsetting. The information will help us to adjust our care to better serve and comfort your pet. Please answer the following questions to the best of your ability so we can take into consideration both your and your pet’s preferences.

1Basic Info

2Pet Basics

3Pet Questions

4Review + Submit

Owner's Name(Required)

First Last

Pet's Name(Required)

Does your pet show any reluctance to getting in the carrier or car?(Required)

Yes

How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.)(Required)

During travel to the veterinary hospital, does your pet do any of the following?(Required)

Eager/excited

Subdued

Reluctant

Bark/Meow

Hide

Whine

Drool

Pant

Vomit

Tremble

Urine/BM

Pace

None of the above

Other…

Check all that apply.

Other (explain)(Required)

Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments later.(Required)

Getting in their carrier or the car

Entering the veterinary hospital

Other pets and/or people passing by while in reception/check-in

Waiting with other people and animals in the waiting area

Being approached by veterinary staff

Getting on the scale for weight

Hearing the doorbell, overhead intercom, or phones ringing

Sounds coming from the back areas of the practice

Going into the exam room

Being put up on the table for examination

Having direct eye contact with the technician and/or veterinarian

Loud voices during examination

Having a rectal temperature taken

The use of instruments such as the stethoscope or otoscope (to look in the ears)

Being taken out of the exam room for procedures

None of the above

Check all that apply.

How would you describe your pet around other animals and people.(Required)

Does your pet have any sensitive areas that she/he does not like to have touched by you or others?(Required)

Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (e.g. nail trims, weight, temperature, ear exam, blood draw, etc). If so, how did your pet react?(Required)

What are your pet's favorite treats? (Please bring some to your next visit to our hospital)(Required)

Does your pet like to play with toys? If so, what kinds?(Required)

Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience?(Required)

Is there anything else you'd like us to know about your pet?

Review the info below. If you need to change anything you can go back in steps to do so. Otherwise, click the submit button to submit the form.

{all_fields}

Having an issue submitting the form?

Forms

New Patient Form

Your Pet's Health History

Terms & Policies

Cat Break!

Pre-Visit Form

(603) 447-3449

At Conway Veterinary Hospital we promote happier, healthier lives by offering patient focused care in a friendly environment that feels like home.

Forms

New Patient Form

Your Pet's Health History

Terms & Policies

Cat Break!

Pre-Visit Form

Need an appointment for your pet?

(603) 447-3449

At Conway Veterinary Hospital we promote happier, healthier lives by offering patient focused care in a friendly environment that feels like home.